GP Connect - Access Record Structured

What is a problem?

A "Problem" is a concept supported by all the GP clinical systems that allows a clinician to identify/highlight specific clinical items in the medical record to describe the status of the patient’s health.

Any clinical item can be identified as a problem, though the method of doing this varies between GP clinical systems.

Examples of possible problems:

Anxiety with depression
Swollen legs
Hypertension
Blood pressure recorded by patient at home
Atrial fibrillation
Knee pain
Upper respiratory tract infection
Lives alone

As well as highlighting an item, the problem record also links that item to all the other information in the patient record that describes what has happened in regard to that item. For example, the problems record highlights that the patient has hypertension. It also shows how the hypertension was identified, what discussions have taken place with the patient about their hypertension and what treatments and medication the patient is on to help manage their hypertension.

To support this, problems are linked to:

every consultation where the problem has been discussed or information about the problem has been recorded
every clinical item in the patient record that a clinician has identified as relevant to the problem (for example, test results, medication)
every other problem in the patient record that a clinician has identified as relevant to the problem

Problem relationships

Problem records are linked to consultations, clinical items and other problems. Different provider systems manage links to problems in different ways. To reduce the impact of this to consumers, the provider system will transform their problem linkages into a common model for export.

Note: The diagrams are illustrative to support the specification text. There may be some simplifications or omissions, for instance not all possible linkages to the resources for investigations are shown.

GPConnect-problem-guidance.drawio

Clinical item references

When a clinical item is linked to the problem, a reference to its FHIR® resource is held in either extension[actualProblem] or extension[relatedClinicalContent].

When linking to the clinical item that is held in a single FHIR resource the reference will be to that resource. When linking to the clinical item that is held across multiple resources (for example, Medication and Medical Device) the reference must be to the FHIR resource specified below.

A planned prescription with a medication or medical device can be represented with the CareConnect-GPC-MedicationRequest-1 profile, with the intent element, containing the value of plan
An issued prescription with a medication or medical device can be represented with the CareConnect-GPC-MedicationRequest-1 profile, with the intent element, containing the value of order
An allergy can be represented with the CareConnect-AllergyIntolerance-1 profile
An consultation can be referenced with the CareConnect-GPC-Encounter-1 profile
An immunisation can be referenced with the CareConnect-GPC-Immunization-1 profile
Uncategorised data can be represented with the CareConnect-GPC-Observation-1 profile
A referral can be represented with the CareConnect-GPC-ReferralRequest-1 profile
A document can be represented with the CareConnect-GPC-DocumentReference-1 profile
An investigation can be represented with the CareConnect-GPC-DiagnosticReport-1 profile
A diary entry can be represented with the CareConnect-GPC-ProcedureRequest-1 profile

Linking multiple problems

It is possible within GP clinical systems to link problems together. This is done by a clinician when they consider the problems to have a clinical impact or give context to each other.

The methods and terminology used to link problems varies a great deal between clinical systems and are not compatible with each other. For example, in one GP clinical system grouping two problems merges them into a single problem while in another it keeps them as two separate problems that are linked together.

To resolve this, GP Connect will only show the logical linkage between problems (whether the linked problem is a parent, child or sibling) without reflecting the terminology of the provider system.

Problem linkages may be impacted by filtering.

The details on how this is implemented in an API can be found in the API Definition - Retrieve a patient's structured record.

To do: Update link to API when available in API catalogue.

Problems linking to out of scope clinical items

The following items may be recorded in defined clinical areas which are supported by the provider but the clinical items are out of scope in this version of the specification

Complete diary entries
Test requests not part of investigation reports

If these clinical items are linked to a problem, they will not be referenced in the provider response. An encounter reference MUST be included as a reference from the problem where applicable, as defined above, regardless of the absence of a reference to the clinical item.

Problems linking to unsupported clinical items

Depending on the GP Connect version supported by the provider system, it can be possible for the problem to link to a clinical item that the provider system is not yet able to export with GP Connect. For example, if the problem contains a link to a referral record but the provider system does not yet support exporting referrals.

Where a provider system is not able to export a linked clinical item, it will create a reference entry with the:

Condition.extension:relatedClinicalContent.valueReference.display should have the value: "[Clinical area] items are not supported by the provider system."

Where [Clinical area] identifies the type of the clinical item that is not supported.

The example below shows references to two items, one for an observation and another for referrals that aren’t supported by the provider system:

<extension>
    <url value="http://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-RelatedClinicalContent-1" />
    <valueReference value="observation-7634572634" />
</extension>
<extension>
    <url value="http://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-RelatedClinicalContent-1" />
    <valueReference>
        <display value="Referral items are not supported by the provider system" />
    </valueReference>
</extension>

Problems containing confidential items

Where a Problem is marked as confidential it will (as per the structured requirements on confidentially) not be included in returned data and the Confidential Items warning message will be included in the List containing the query response.

Where a Problem is not marked as confidential but includes items that are marked as confidential or are considered sensitive, the following information is returned:

the Problem will be included in the response as normal
the confidential item(s) will NOT be included in the response
there will be NO reference to the confidential item(s) in the ProblemHeader (Condition) profile.
the Confidential Items warning message will be included in the List on the relevant type of type data that was ommitted. For example if a piece of uncategorised data was excluded as it was confidential then the warning code would be in the list of uncategorised data that was returned as part of the query.

In effect, there will be a warning message that items were excluded from the response due to confidentiality but there will be no indication from which Problems(s) they were removed.

Using Problem search parameters

The request for problems supports searching via a part parameter for the problem’s clinical status. Guidance is given in other sections of this specification as to how the provider will populate the response with identifying lists and related clinical content. This section describes consequences of those requirements specific to problems returned.

If the consumer request specifies a part parameter for status, the provider MUST return all problems with matching clinical status.

In addition to the matching problems, the provider MUST return the resource items referenced by the problem header as the actual problem, related problems or related clinical content as described on the Linkages and the Retrieve a patient’s structured record page. The provider MUST include the related problem header resource regardless of whether the related problem matches the specified status, that is if the part parameter requests only active problems, where an active problem is directly related to an inactive one, then the inactive problem header will be returned. The provider MUST include a reference in the problems secondary list to the related problem header which does not match the specified status as described in Using lists to return data. The provider MUST NOT include any resources referenced by the problem header resources in the secondary list which do not match the specified status. The provider MAY include problems in the ‘problems linked to problems’ secondary list which both meet the search criteria and are linked problems. The provider MUST NOT include any problem reference in the primary problem list which are returned only as related problems and do not directly meet the problem search criteria.

A consumer can therefore receive problems which do not meet the specified status, but the consumer can identify such problem header resources as they will be referenced in the ‘problems related to problems’ list but are not referenced by the primary problem’s list.

Using the List resource for problem queries

The results of a query for problem details MUST return a List containing references to all ProblemHeader (Condition) resources that are returned.

The List MUST be populated in line with the guidance on List resources.

If the List is empty, then an empty List MUST be returned with an emptyReason.code with the value no-content-recorded. In this case, List.note MUST be populated with the text ‘Information not available’.