Encounter Summary

Encounter Summary is a compilation of different records assembled during a patient's healthcare encounter event. It can be as holistic and detailed from the start to the end of an encounter with multiple records being created and updated as an encounter progresses (from arrived to in-progress to finished) or as a single snapshot of an encounter where information is sufficient enough for meaningful information exchange such as at the end of an encounter in a form of a discharge/visit summary depending on the feasibilty and integration scope of an agreed information exhange project.


Scope and Usage

This section of use case is meant to outline a general proposed scope of integeration that can be used as a baseline of information sharing with regards to the MY Core profile and base FHIR standard.


Boundaries and Relationship

The main resources used for retrieval/referencing supporting resources are Composition (MY Core) and Encounter (MY Core).

Other supporting resource such as Condition (MY Core), AllergyIntolerance (MY Core), MedicationRequest (MY Core), DiagnosticReport (MY Core) or Observation profile will reference or be referenced by the main resources to link the records for easier record retrieval.

If the integration scope is limited, the referral summary can be shared within the Composition resource as a narrative xhtml instead of multiple resources. This would at least ensure that information shared can achieve the continuation of care objective of the HIE project. However, this scope of integration will most likely result in difficulties and less reliable data for later operational or analytical purposes.

Scenarios

Below are some of the use case scenarios that can be used depending on the scope of integration.

Click MY Core postman API link to view common API used in HIE.

Composition only

This scenario only requires a composition record to be shared. Source system can send record in multiple section in a composition or in a single section "Clinical Information" Composition.section.where (code.coding.code = '55752-0').text

However, Composition (MY Core) mandatories that;

  • a patient record must first exist Composition.subject to be referenced.
  • a custodian (facility that maintains the composition) must first exist Composition.custodian to be referenced.

Related Profile: Composition (MY Core), Patient (MY Core), Encounter (MY Core) and Organization (MY Core).


[base] = address url e.g. "https://fhir.hie.moh.gov.my/baseR4/"
[type] = resource type e.g. "Patient | Encounter | Compostion"
@recordId = unique record id defined from source system e.g. "composition-sample"
@encounterId = unique encounter id defined from source system e.g. "encounter-sample"
@encounterIdentifier = encounter registrtion number defined from source system e.g "HTJ-ENC-2211000036"
@patientId = unique patient id defined from source system e.g "patient-sample"
@patientIdentifier = patient identifier such as mykad number or MRN e.g "HIE-00000003"

Sample Description Sample Body API Method API
Create/Update Composition only

1.multiple section sample,

2.single section template (MyHix),

3.single section sample (MyHix)

PUT [base]/Composition/@recordId
Retrieve by record id - GET [base]/[type]/@recordId
Retrieve record by encounter id - GET [base]/[type]?encounter=@encounterId
Retrieve record by encounter identifier - GET [base]/[type]?encounter.identifier=@encounterIdentifier
Retrieve record by patient id - GET [base]/[type]?subject=@patientId
Retrieve record by patient identifier - GET [base]/[type]?subject.identifier=@patientIdentifier

Composition with supporting records

This method of data sharing uses Bundle opearation where multiple resource will be send together within a single request.

The supporting document sent varies depending on the integration scope of each project.

A Bundle transaction is not stored in the server as it is only created transiently as a means of trasporting records. Thus, it is highly recommended for source system to assign a unique record id for each of their record for easier retrieval and updating purposes if able. Else, if no id is provided the server will auto generate a random unique 32 alphanumerical id which source system can store via their own respective method for later retrieval/updating purposes.

Related profile: Patient (MY Core), Composition (MY Core), Encounter (MY Core), Condition (MY Core), AllergyIntolerance (MY Core), Medication (MY Core), Observation profile, DiagnosticReport (MY Core) and Procedure (MY Core)


[base] = address url e.g. "https://fhir.hie.moh.gov.my/baseR4/"
[type] = resource type e.g. "Patient | Encounter | Compostion"
@recordId = unique record id defined from source system e.g. "composition-sample"
@encounterId = unique encounter id defined from source system e.g. "encounter-sample"
@encounterIdentifier = encounter registrtion number defined from source system e.g "HTJ-ENC-2211000036"
@patientId = unique patient id defined from source system e.g "patient-sample"
@patientIdentifier = patient identifier such as mykad number or MRN e.g "HIE-00000003"
@panelObservationId = unique observation panel id defined from source system e.g. "obs-vs-sample"

Sample Description Sample Body API Method API
Create/Update encounter bundle

1.bundle with id,

2.bundle without id

POST [base]
Retrieve by record id - GET [base]/[type]/@recordId
Retrieve record by encounter id - GET [base]/[type]?encounter=@encounterId
Retrieve record by encounter identifier - GET [base]/[type]?encounter.identifier=@encounterIdentifier
Retrieve record by patient id - GET [base]/[type]?subject=@patientId
Retrieve record by patient identifier - GET [base]/[type]?subject.identifier=@patientIdentifier
Retrieve observation panel record with its has-member record - GET [base]/Observation?_include=Observation:has-member&_id=@panelObservationId

Amend Composition

A composition record can also be amended, the initial amended composition will be updated to amended status Composition.status=amended and if an appended attachment record exist, record will be store in an amended section in Composition with section code Composition.section.where (code.coding.code = '55107-7').text

Any supporting record can also be updated if required either individually or together within a bundle.

Related Profile: Composition (MY Core)


[base] = address url e.g. "https://fhir.hie.moh.gov.my/baseR4/"
[type] = resource type e.g. "Patient | Encounter | Compostion"
@compositionId = unique composition id defined from source system e.g. "composition-sample"

Sample Description Sample Body API Method API
Amend composition only JSON PUT [base]/Composition/@compositionId
Amend composition with supporting record JSON PUT [base]

Delete Composition

A composition record can be logically deleted by updating the status Composition.status=entered-in-error

Related Profile: Composition (MY Core)


[base] = address url e.g. "https://fhir.hie.moh.gov.my/baseR4/"
[type] = resource type e.g. "Patient | Encounter | Compostion"
@compositionId = unique composition id defined from source system e.g. "composition-sample"

Sample Description Sample Body API Method API
Delete composition only JSON PUT [base]/Composition/@compositionId


External Reference

Refer "Composition only" under Scenarios for sample JSON

The JSON template is only meant as a suggestion, it is up to each respective source system to decide on the method/scope of integration and entry of record template as long as data can be properly shared and viewed in HIE portal.

Data Elements Description Cardinality FHIR Element ID
Document Set - Profile:Composition (MY Core)
Document unique id A unique identifier of the document 0..1 Composition.id
Document repositpry unique id A repository unique identifier of the document (UUID) 0..1 Composition.identifier.where (system = 'http://fhir.hie.moh.gov.my/sid/composition-id').value
Document title A descriptive title of the document (eg: Hospital Discharge Summary) 1..1 Composition.title
Document confidentiality R=Restricted, V=Very Restricted 0..1 Composition.meta.security
Document creation time Time-stamp when original document was created 1..1 Composition.date
Parent document id A unique identifier of previous document (when applicable) 0..* Composition.relatesTo.targetReference
Parent document relationship Identifier on how document is related to previous version (when applicable) 0..1 Composition.relatesTo.code
Custodian - Profile: Composition (MY Core)
OID Unique ID assign to facility Composition.custodian.reference
Name Composition.custodian.display
Address Address Type refer Telecommunication Address Use table N/A Composition.custodian.reference:Organization.address
Patient - Profile: Patient (MY Core)
Name 1..1 Patient.name.given
Gender Gender code refer Patient Gender table 1..1 Patient.gender
DOB 1..1 Patient.birthDate
Race 0..1 Patient.extension.where (url = 'http://fhir.hie.moh.gov.my/StructureDefinition/ethnic-my-core')
MRN 1..1 Patient.identifier.where (system = 'http://fhir.hie.moh.gov.my/sid/patient-mrn').value
Address Address Type refer Telecommunication Address Use table 0..1 Patient.address
Phone home Phone Type refer Telecommunication Address Use table 0..1 Patient.telecom.where (use = 'home').where (system ='phone').value
Phone office Phone Type refer Telecommunication Address Use table 0..1 Patient.telecom.where (use = 'work').where (system ='phone').value
Fax Phone Type refer Telecommunication Address Use table 0..1 Patient.telecom.where (system ='fax').value
Email address Phone Type refer Telecommunication Address Use table 0..1 Patient.telecom.where (system ='email').value
National Id IC 0..1 Patient.identifier.where (system = 'http://fhir.hie.moh.gov.my/sid/my-kad-no').value
Author - Profile: Composition (MY Core)
Name 0..1 Composition.author.where (type= 'PractitionerRole').display
MMC MMC registration number 0..1 Composition.author.where (type= 'PractitionerRole').identifier.where (system = 'http://fhir.hie.moh.gov.my/sid/mmc-no').value
Facility OID Composition.custodian.reference
Facility name Composition.custodian.display
Time Time-stamp when the original document was saved 0..1 Composition.event.period.start
Cosultant - Profile: Composition (MY Core)
Name 0..1 Composition.attester.party.where (type = 'PractitionerRole').display
MMC 0..1 Composition.attester.party.where (type = 'PractitionerRole').identifier.where (system = 'http://fhir.hie.moh.gov.my/sid/mmc-no').value
Facility OID Composition.custodian.reference
Facility name Composition.custodian.display
Time Time-stamp when the original document was approved 0..1 Composition.attester.time
Visit/Encounter - Profile: Encounter (MY Core)
Admission date 1..0 Encounter.period.start
Discharge date 0..1 Encounter.period.end
Visit id 0..1 Encounter.identifier.where (system ='http://fhir.hie.moh.gov.my/sid/encounter-id').value
Time Time-stamp when patient request for service. 0..1 Encounter.statusHistory.where (status = 'planned').period.start
Assign doctor name 0..1 Encounter.participant.where (type.coding.code = 'PPRF').individual.display
Assign doctor MMC 0..1 Encounter.participant.where (type.coding.code = 'PPRF').individual.identifier.where (system = 'http://fhir.hie.moh.gov.my/sid/mmc-no').value
Assign doctor facility OID 1..1 Encounter.serviceProvider.reference
Assign doctor facility name 1..1 Encounter.serviceProvider.display
Service id Refer DSDLOC table 1..1 Encounter.type.coding.where (system = 'http://fhir.hie.moh.gov.my/CodeSystem/specialty-my-core').code
Allergies - Profile: AllergyIntolerance (MY Core)
Allergies and Other Adverse Reactions 0..1 AllergyIntolerance.code.coding.where (system = 'http://fhir.hie.moh.gov.my/CodeSystem/active-ingredient-my-core').code
Reason for care - Profile: Encounter (MY Core)
Hospital Admission Diagnosis 0..* Encounter.diagnosis.where (use.coding.code = 'AD').condition.reference
Other Condition Histories - Profile: Encounter (MY Core)
Active Problems 0..* Encounter.diagnosis.where (use.coding.code = '08' or use.coding.code = '01')
Discharge Diagnosis 0..* Encounter.diagnosis.where (use.coding.code = 'DD').condition.reference
Resolved Problems 0..* Encounter.diagnosis.reference:Condition.clinicalStatus=resolved
List of Surgeries 0..* Encounter.diagnosis.condition.where (type = 'Procedure').reference:Procedure.code.coding.code
Medication - Profile: Medication (MY Core)
Medications 0..* MedicationRequest.medicationCodeableConcept.coding.code
Relevant Studies - Profile: Observation profile, DiagnosticReport (MY Core)
Results 0..* Observation.code.coding.code
Hospital Discharge Studies Summary 0..* DiagnosticReport.coding.code
Plans of Care - Profile: Composition (MY Core)
Care Plan 0..1 Composition.section.where (code.coding.code = '18776-5').text
Correspondence Facility - Profile:
OID Unique ID assign to facility
Name
Address Address Type refer Telecommunication Address Use table
Close

Scope and Usage

This section of use case is meant to outline a general proposed scope of integeration that can be used as a baseline of information sharing with regards to the MY Core profile and base FHIR standard.


Boundaries and Relationship

The main resources used for retrieval/referencing supporting resources are Composition (MY Core) and Encounter (MY Core).

Other supporting resource such as Condition (MY Core), AllergyIntolerance (MY Core), MedicationRequest (MY Core), DiagnosticReport (MY Core) or Observation profile will reference or be referenced by the main resources to link the records for easier record retrieval.

If the integration scope is limited, the referral summary can be shared within the Composition resource as a narrative xhtml instead of multiple resources. This would at least ensure that information shared can achieve the continuation of care objective of the HIE project. However, this scope of integration will most likely result in difficulties and less reliable data for later operational or analytical purposes.

Scenarios

Below are some of the use case scenarios that can be used depending on the scope of integration.

Click MY Core postman API link to view common API used in HIE.

Composition only

This scenario only requires a composition record to be shared. Source system can send record in multiple section in a composition or in a single section "Clinical Information" Composition.section.where (code.coding.code = '55752-0').text

However, Composition (MY Core) mandatories that;

  • a patient record must first exist Composition.subject to be referenced.
  • a custodian (facility that maintains the composition) must first exist Composition.custodian to be referenced.

Related Profile: Composition (MY Core), Patient (MY Core), Encounter (MY Core) and Organization (MY Core).


[base] = address url e.g. "https://fhir.hie.moh.gov.my/baseR4/"
[type] = resource type e.g. "Patient | Encounter | Compostion"
@recordId = unique record id defined from source system e.g. "composition-sample"
@encounterId = unique encounter id defined from source system e.g. "encounter-sample"
@encounterIdentifier = encounter registrtion number defined from source system e.g "HTJ-ENC-2211000036"
@patientId = unique patient id defined from source system e.g "patient-sample"
@patientIdentifier = patient identifier such as mykad number or MRN e.g "HIE-00000003"

Sample Description Sample Body API Method API
Create/Update Composition only

1.multiple section sample,

2.single section template (MyHix),

3.single section sample (MyHix)

PUT [base]/Composition/@recordId
Retrieve by record id - GET [base]/[type]/@recordId
Retrieve record by encounter id - GET [base]/[type]?encounter=@encounterId
Retrieve record by encounter identifier - GET [base]/[type]?encounter.identifier=@encounterIdentifier
Retrieve record by patient id - GET [base]/[type]?subject=@patientId
Retrieve record by patient identifier - GET [base]/[type]?subject.identifier=@patientIdentifier

Composition with supporting records

This method of data sharing uses Bundle opearation where multiple resource will be send together within a single request.

The supporting document sent varies depending on the integration scope of each project.

A Bundle transaction is not stored in the server as it is only created transiently as a means of trasporting records. Thus, it is highly recommended for source system to assign a unique record id for each of their record for easier retrieval and updating purposes if able. Else, if no id is provided the server will auto generate a random unique 32 alphanumerical id which source system can store via their own respective method for later retrieval/updating purposes.

Related profile: Patient (MY Core), Composition (MY Core), Encounter (MY Core), Condition (MY Core), AllergyIntolerance (MY Core), Medication (MY Core), Observation profile, DiagnosticReport (MY Core) and Procedure (MY Core)


[base] = address url e.g. "https://fhir.hie.moh.gov.my/baseR4/"
[type] = resource type e.g. "Patient | Encounter | Compostion"
@recordId = unique record id defined from source system e.g. "composition-sample"
@encounterId = unique encounter id defined from source system e.g. "encounter-sample"
@encounterIdentifier = encounter registrtion number defined from source system e.g "HTJ-ENC-2211000036"
@patientId = unique patient id defined from source system e.g "patient-sample"
@patientIdentifier = patient identifier such as mykad number or MRN e.g "HIE-00000003"
@panelObservationId = unique observation panel id defined from source system e.g. "obs-vs-sample"

Sample Description Sample Body API Method API
Create/Update encounter bundle

1.bundle with id,

2.bundle without id

POST [base]
Retrieve by record id - GET [base]/[type]/@recordId
Retrieve record by encounter id - GET [base]/[type]?encounter=@encounterId
Retrieve record by encounter identifier - GET [base]/[type]?encounter.identifier=@encounterIdentifier
Retrieve record by patient id - GET [base]/[type]?subject=@patientId
Retrieve record by patient identifier - GET [base]/[type]?subject.identifier=@patientIdentifier
Retrieve observation panel record with its has-member record - GET [base]/Observation?_include=Observation:has-member&_id=@panelObservationId

Amend Composition

A composition record can also be amended, the initial amended composition will be updated to amended status Composition.status=amended and if an appended attachment record exist, record will be store in an amended section in Composition with section code Composition.section.where (code.coding.code = '55107-7').text

Any supporting record can also be updated if required either individually or together within a bundle.

Related Profile: Composition (MY Core)


[base] = address url e.g. "https://fhir.hie.moh.gov.my/baseR4/"
[type] = resource type e.g. "Patient | Encounter | Compostion"
@compositionId = unique composition id defined from source system e.g. "composition-sample"

Sample Description Sample Body API Method API
Amend composition only JSON PUT [base]/Composition/@compositionId
Amend composition with supporting record JSON PUT [base]

Delete Composition

A composition record can be logically deleted by updating the status Composition.status=entered-in-error

Related Profile: Composition (MY Core)


[base] = address url e.g. "https://fhir.hie.moh.gov.my/baseR4/"
[type] = resource type e.g. "Patient | Encounter | Compostion"
@compositionId = unique composition id defined from source system e.g. "composition-sample"

Sample Description Sample Body API Method API
Delete composition only JSON PUT [base]/Composition/@compositionId


External Reference

Refer "Composition only" under Scenarios for sample JSON

The JSON template is only meant as a suggestion, it is up to each respective source system to decide on the method/scope of integration and entry of record template as long as data can be properly shared and viewed in HIE portal.

Data Elements Description Cardinality FHIR Element ID
Document Set - Profile:Composition (MY Core)
Document unique id A unique identifier of the document 0..1 Composition.id
Document repositpry unique id A repository unique identifier of the document (UUID) 0..1 Composition.identifier.where (system = 'http://fhir.hie.moh.gov.my/sid/composition-id').value
Document title A descriptive title of the document (eg: Hospital Discharge Summary) 1..1 Composition.title
Document confidentiality R=Restricted, V=Very Restricted 0..1 Composition.meta.security
Document creation time Time-stamp when original document was created 1..1 Composition.date
Parent document id A unique identifier of previous document (when applicable) 0..* Composition.relatesTo.targetReference
Parent document relationship Identifier on how document is related to previous version (when applicable) 0..1 Composition.relatesTo.code
Custodian - Profile: Composition (MY Core)
OID Unique ID assign to facility Composition.custodian.reference
Name Composition.custodian.display
Address Address Type refer Telecommunication Address Use table N/A Composition.custodian.reference:Organization.address
Patient - Profile: Patient (MY Core)
Name 1..1 Patient.name.given
Gender Gender code refer Patient Gender table 1..1 Patient.gender
DOB 1..1 Patient.birthDate
Race 0..1 Patient.extension.where (url = 'http://fhir.hie.moh.gov.my/StructureDefinition/ethnic-my-core')
MRN 1..1 Patient.identifier.where (system = 'http://fhir.hie.moh.gov.my/sid/patient-mrn').value
Address Address Type refer Telecommunication Address Use table 0..1 Patient.address
Phone home Phone Type refer Telecommunication Address Use table 0..1 Patient.telecom.where (use = 'home').where (system ='phone').value
Phone office Phone Type refer Telecommunication Address Use table 0..1 Patient.telecom.where (use = 'work').where (system ='phone').value
Fax Phone Type refer Telecommunication Address Use table 0..1 Patient.telecom.where (system ='fax').value
Email address Phone Type refer Telecommunication Address Use table 0..1 Patient.telecom.where (system ='email').value
National Id IC 0..1 Patient.identifier.where (system = 'http://fhir.hie.moh.gov.my/sid/my-kad-no').value
Author - Profile: Composition (MY Core)
Name 0..1 Composition.author.where (type= 'PractitionerRole').display
MMC MMC registration number 0..1 Composition.author.where (type= 'PractitionerRole').identifier.where (system = 'http://fhir.hie.moh.gov.my/sid/mmc-no').value
Facility OID Composition.custodian.reference
Facility name Composition.custodian.display
Time Time-stamp when the original document was saved 0..1 Composition.event.period.start
Cosultant - Profile: Composition (MY Core)
Name 0..1 Composition.attester.party.where (type = 'PractitionerRole').display
MMC 0..1 Composition.attester.party.where (type = 'PractitionerRole').identifier.where (system = 'http://fhir.hie.moh.gov.my/sid/mmc-no').value
Facility OID Composition.custodian.reference
Facility name Composition.custodian.display
Time Time-stamp when the original document was approved 0..1 Composition.attester.time
Visit/Encounter - Profile: Encounter (MY Core)
Admission date 1..0 Encounter.period.start
Discharge date 0..1 Encounter.period.end
Visit id 0..1 Encounter.identifier.where (system ='http://fhir.hie.moh.gov.my/sid/encounter-id').value
Time Time-stamp when patient request for service. 0..1 Encounter.statusHistory.where (status = 'planned').period.start
Assign doctor name 0..1 Encounter.participant.where (type.coding.code = 'PPRF').individual.display
Assign doctor MMC 0..1 Encounter.participant.where (type.coding.code = 'PPRF').individual.identifier.where (system = 'http://fhir.hie.moh.gov.my/sid/mmc-no').value
Assign doctor facility OID 1..1 Encounter.serviceProvider.reference
Assign doctor facility name 1..1 Encounter.serviceProvider.display
Service id Refer DSDLOC table 1..1 Encounter.type.coding.where (system = 'http://fhir.hie.moh.gov.my/CodeSystem/specialty-my-core').code
Allergies - Profile: AllergyIntolerance (MY Core)
Allergies and Other Adverse Reactions 0..1 AllergyIntolerance.code.coding.where (system = 'http://fhir.hie.moh.gov.my/CodeSystem/active-ingredient-my-core').code
Reason for care - Profile: Encounter (MY Core)
Hospital Admission Diagnosis 0..* Encounter.diagnosis.where (use.coding.code = 'AD').condition.reference
Other Condition Histories - Profile: Encounter (MY Core)
Active Problems 0..* Encounter.diagnosis.where (use.coding.code = '08' or use.coding.code = '01')
Discharge Diagnosis 0..* Encounter.diagnosis.where (use.coding.code = 'DD').condition.reference
Resolved Problems 0..* Encounter.diagnosis.reference:Condition.clinicalStatus=resolved
List of Surgeries 0..* Encounter.diagnosis.condition.where (type = 'Procedure').reference:Procedure.code.coding.code
Medication - Profile: Medication (MY Core)
Medications 0..* MedicationRequest.medicationCodeableConcept.coding.code
Relevant Studies - Profile: Observation profile, DiagnosticReport (MY Core)
Results 0..* Observation.code.coding.code
Hospital Discharge Studies Summary 0..* DiagnosticReport.coding.code
Plans of Care - Profile: Composition (MY Core)
Care Plan 0..1 Composition.section.where (code.coding.code = '18776-5').text
Correspondence Facility - Profile:
OID Unique ID assign to facility
Name
Address Address Type refer Telecommunication Address Use table
Close