Integration Point

Pharmacy Integration Use Case (Version 0.1c)

Introduction

Integration between Pharmacy Information System (PhIS) with HIE falls within HIE scope of deliverables.

Objective

This section is to provide a reference point and integration use case scenario for developers. It is also used as a documentation of high level integration agreement between HIE and PhIS

Overview

These are the agreed integration points:

No	Integration Point	Data From	Data To	Frequency	Remark
1	Master Drug List	PhIS IWP	HIE	Daily	HIE initiate existing IWP API with last sync date parameter to get latest Master Data
2	Facility Drug List	PhIS IWP	HIE	Daily	HIE initiate PhIS API with last sync date parameter to get the latest facility drug master
3	Patient Registration	PhIS	HIE	Daily	PhIS initiate HIE FHIR API to send the latest records
4	Allergy	PhIS	HIE	Daily	PhIS initiate HIE FHIR API to send the latest records
5	Allergy Negation Statement	PhIS	HIE	Daily	PhIS initiate HIE FHIR API to send the latest records
6	MTAC summary	PhIS	HIE	Daily	PhIS initiate HIE FHIR API to send the latest records. Submit upon completed
7	ADR Report	PhIS	HIE	Daily	PhIS initiate HIE FHIR API to send the latest records
8	MC summary	PhIS	HIE	Daily	PhIS initiate HIE FHIR API to send the latest records. Submit upon completed
9	Medication Order	-	-	No Integration	Presciption will be done in Rekod Pesakit and printed. Pharmacist will then transcribe the prescription note into PhIS manually
10	Encounter Registration	-	-	No Integration	Refer PhIS for encounter record
11	TDM Reporting	-	-	No Integration	Refer to LIS
12	Dispensing	-	-	No Integration	Refer to PhIS for dispensing records
13	VC Scheduling & Appointment	-	-	No Integration	Virtual Consultation, Scheduling and Appointment in Rekod Pesakit

Integration Point

Back to Overview

Patient Registration

Scenario: PhIS will send patient record to HIE

Related Profile: Patient (MY Core)

Example JSON

{
    "resourceType": "Patient",
    "id": "example-patient-phis",
    "meta": {
        "versionId": "4",
        "lastUpdated": "2022-12-19T06:54:52.308+08:00",
        "source": "http://phis.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Patient-my-core"
        ]
    },
    "extension":  [
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core",
            "extension":  [
                {
                    "url": "recorder",
                    "valueReference": {
                        "display": "First Recorder Practitioner Name"
                    }
                },
                {
                    "url": "recordedDate",
                    "valueDateTime": "2022-12-19T12:34:00+08:00"
                },
                {
                    "url": "lastUpdater",
                    "valueReference": {
                        "display": "Last Updater Practitioner Name"
                    }
                }
            ]
        },
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/education-level-my-core",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/education-level-my-core",
                        "code": "4",
                        "display": "tertiary"
                    }
                ]
            }
        },
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/religion-my-core",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/religion-my-core",
                        "code": "1",
                        "display": "Islam"
                    }
                ]
            }
        },
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/ethnic-my-core",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/ethnic-my-core",
                        "code": "01",
                        "display": "Melayu"
                    }
                ]
            }
        }
    ],
    "identifier":  [
        {
            "system": "http://fhir.hie.moh.gov.my/sid/my-kad-no",
            "value": "921005141234"
        },
        {
            "system": "http://fhir.hie.moh.gov.my/sid/patient-mrn",
            "value": "PHIS-123"
        }
    ],
    "active": true,
    "name":  [
        {
            "extension":  [
                {
                    "url": "http://fhir.hie.moh.gov.my/StructureDefinition/person-title-my-core",
                    "valueCodeableConcept": {
                        "coding":  [
                            {
                                "system": "http://fhir.hie.moh.gov.my/CodeSystem/person-title-my-core",
                                "code": "L001",
                                "display": "Encik"
                            }
                        ]
                    }
                }
            ],
            "given":  [
                "PHIS patient name example"
            ]
        }
    ],
    "telecom":  [
        {
            "system": "phone",
            "value": "014454120315"
        },
        {
            "system": "email",
            "value": "hieperson@gmail.com"
        }
    ],
    "gender": "male",
    "birthDate": "1992-10-05",
    "deceasedBoolean": false,
    "address":  [
        {
            "extension":  [
                {
                    "url": "http://fhir.hie.moh.gov.my/StructureDefinition/address-district-my-core",
                    "valueCodeableConcept": {
                        "coding":  [
                            {
                                "system": "http://fhir.hie.moh.gov.my/CodeSystem/district-my-core",
                                "code": "0505",
                                "display": "Seremban"
                            }
                        ]
                    }
                },
                {
                    "url": "http://fhir.hie.moh.gov.my/StructureDefinition/address-state-my-core",
                    "valueCodeableConcept": {
                        "coding":  [
                            {
                                "system": "http://fhir.hie.moh.gov.my/CodeSystem/state-my-core",
                                "code": "05",
                                "display": "Negeri Sembilan"
                            }
                        ]
                    }
                }
            ],
            "use": "home",
            "line":  [
                "No. 1, Jalan Bangsar 7/3"
            ],
            "city": "Laman Pelangi",
            "postalCode": "02196",
            "country": "MYS"
        }
    ],
    "contact":  [
        {
            "name": {
                "given":  [
                    "PHIS contact name example"
                ]
            },
            "telecom":  [
                {
                    "system": "phone",
                    "value": "01527893031",
                    "use": "mobile"
                }
            ],
            "gender": "male"
        }
    ],
    "managingOrganization": {
        "reference": "Organization/PHIS",
        "display": "Pharmacy Information System (PhIS)"
    }
}

API

Operation	Address	Request Method	Example
Create Record	[base]/Patient/@FacilityMrnIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Patient/HTJ-PHIS-123
Update Record	[base]/Patient/@FacilityMrnIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Patient/HTJ-PHIS-123
Read Record	[base]/Patient/@FacilityMrnIdentifier	GET	https://fhir.hie.moh.gov.my/baseR4/Patient/HTJ-PHIS-123

Mapping

HIE Item	Element Description	Cardinality	ValueSet/Remark	FHIR Element	FHIR Elemet DataType
Profile	Profiles this resource claims to conform to	1..1	http://fhir.hie.moh.gov.my/StructureDefinition/Patient-my-core	Patient.meta.profile	Canonical
Patient Details
Identification (My Kad)	My Kad no identifier	0..1	At least 1 identifier	Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/my-kad-no	String
Identification (Passport)	Passport no identifier	0..1	At least 1 identifier	Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/passport-no	String
Identification (Army)	Army no identifier	0..1	At least 1 identifier	Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/army-no	String
Identification (Police)	Police no identifier	0..1	At least 1 identifier	Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/police-no	String
Identification (MRN no)	MRN no identifier	1..1	MRN mandatory from source system	Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/patient-mrn	String
Identification (Other)	Other no identifier	0..1	At least 1 identifier	Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/others-no	String
Identification (Unknown)	Unknown no identifier	0..1	At least 1 identifier	Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/unknown-no	String
Child	Whether or not this record is a child record	1..1 If Identification (Newborn) value exist, else 0..1		Patient.identifier.extension.extension.valueBoolean where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/child-identification-my-core and Patient.extension.extension.url=child	Boolean
ChildType	Which guardian is child using identifier (mother/father/guardian)	1..1 If Identification (Newborn) value exist, else 0..1	ValueSetChildIdentificationType (MY Core)	Patient.identifier.extension.extension.valueCodeableConcept where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/child-identification-my-core and Patient.extension.extension.url=childType	CodeableConcept
ChildNo	Child number	0..1		Patient.identifier.extension.extension.valueQuantity where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/child-identification-my-core and Patient.extension.extension.url=childNo	Integer
Parent No (Mother ID)	Guardian no identifier	1..1 If Identification (Newborn) value exist, else 0..1		Patient.identifier.extension.extension.valueString where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/child-identification-my-core and Patient.extension.extension.url=parentIdentification	String
Title	Title given to patient	1..1	ValueSetPersonTitle (MY Core)	Patient.name.extension.valueCodeableConcept.coding.code where system=http://fhir.hie.moh.gov.my/StructureDefinition/person-title-my-core
Name	Given name.	1..1		Patient.name.given	String
Gender	The gender of a person used for administrative purposes.	1..1	ValueSetAdministrativeGender (MY Core)	Patient.gender	Code
Birth Date	The date of birth for the individual	1..1	FHIR Format YYYY-MM-DD	Patient.birthDate	Date
Ethnic	Ethnic of individual	0..1	ValueSetEthnic (MY Core)	Patient.extension.valueCodeableConcept.coding.code where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/ethnic-my-core	CodeableConcept
Religion	Religion of individual	0..1	ValueSetReligion (MY Core)	Patient.extension.valueCodeableConcept.coding.code where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/religion-my-core	CodeableConcept
Education Level	Education level of individual	0..1	ValueSetEducationLevel (MY Core)	Patient.extension.valueCodeableConcept.coding.code where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/education-level-my-core	CodeableConcept
Phone Number	Phone number of individual	0..*		Patient.telecom.value where Patient.telecom.system=phone	String
Email Address	Email number of indivdual	0..1		Patient.telecom.value where Patient.telecom.system=email	String
Deceased Status	Indicates if the individual is deceased or not	0..1		Patient.deceasedBoolean	Boolean
Status	Whether this patient's record is in active use	0..1		Patient.active	Boolean
Source System	Source System that is the custodian of the patient record	1..1	Hardcode value as "Organization/PHIS"	Patient.managingOrganization.reference	Reference
Address
Line	Street name, number, direction & P.O. Box etc.	0..1		Patient.address.line	String
Postal Code	Postal code for area	0..1		Patient.address.postalCode	String
Country	Country - a nation as commonly understood or generally accepted.	0..1		Patient.country	String
State	Sub-unit of country	0..1	ValueSetState (MY Core)	Patient.address.extension.valueCodeableConcept.coding.code where Patient.address.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/address-state-my-core	CodeableConcept
District	District name	0..1	ValueSetDistrict (MY Core)	Patient.address.extension.valueCodeableConcept.coding.code where Patient.address.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/address-district-my-core	CodeableConcept
City	Name of city, town etc.	0..1		Patient.address.city	String
Contact (Next of Kin)
Name	A name associated with the contact person.	0..1		Patient.contact.name.given	String
Gender	The gender of a person used for administrative purposes.	0..1	ValueSetAdministrativeGender (MY Core)	Patient.contact.gender	Code
Phone Number	Phone number of contact person	0..1		Patient.contact.telecom.value where Patient.contact.telecom.system=phone	String
Email Address	Email number of contact person	0..1		Patient.contact.telecom.value where Patient.contact.telecom.system=email	String
Contact Address
Line	Street name, number, direction & P.O. Box etc.	0..1		Patient.contact.address.line	String
Postal Code	Postal code for area	0..1		Patient.contact.address.postalCode	String
Country	Country - a nation as commonly understood or generally accepted.	0..1		Patient.contact.country	String
State	Sub-unit of country	0..1	ValueSetState (MY Core)	Patient.contact.address.extension.valueCodeableConcept.coding.code where Patient.address.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/address-state-my-core	CodeableConcept
District	District name	0..1	ValueSetDistrict (MY Core)	Patient.contact.address.extension.valueCodeableConcept.coding.code where Patient.address.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/address-district-my-core	CodeableConcept
City	Name of city, town etc.	0..1		Patient.contact.address.city	String
Audit
Recorder	Practitioner who first recorded this encounter	0..1		Patient.extension.audit.recorder.valueReference.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=recorder	String
Recorded Date	Date encounter was first recorded	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Patient.extension.audit.recordedDate.valueDateTime.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=recordedDate	DateTime
Updator	Practitioner who last updated this encounter	0..1		Patient.extension.audit.lastUpdater.valueReference.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=lastUpdater	String
Last Updated	Last encounter updated date	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Patient.meta.lastUpdated	DateTime (SystemGenerated)

Encounter Registration

Scenario: PhIS will send encounter record to HIE

Related Profile: Encounter (MY Core)

Example JSON

{
    "resourceType": "Encounter",
    "id": "example-encounter-phis",
    "meta": {
        "source": "http://phis.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Encounter-my-core"
        ]
    },
    "extension":  [
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core",
            "extension":  [
                {
                    "url": "recorder",
                    "valueReference": {
                        "display": "First Recorder Practitioner Name"
                    }
                },
                {
                    "url": "recordedDate",
                    "valueDateTime": "2022-12-19T12:34:00+08:00"
                },
                {
                    "url": "lastUpdater",
                    "valueReference": {
                        "display": "Last Updater Practitioner Name"
                    }
                }
            ]
        }
    ],
    "identifier":  [
        {
            "system": "http://fhir.hie.moh.gov.my/sid/encounter-id",
            "value": "PHIS-ENC-2212000101"
        }
    ],
    "status": "finished",
    "statusHistory":  [
        {
            "status": "arrived",
            "period": {
                "start": "2022-12-19T12:34:00+08:00",
                "end": "2022-12-19T12:45:14+08:00"
            }
        },
        {
            "status": "in-progress",
            "period": {
                "start": "2022-12-19T12:45:14+08:00",
                "end": "2022-12-19T14:23:08+08:00"
            }
        }
    ],
    "class": {
        "system": "http://fhir.hie.moh.gov.my/CodeSystem/encounter-class-my-core",
        "code": "VR",
        "display": "Virtual"
    },
    "type":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/specialty-my-core",
                    "code": "543",
                    "display": "Medication Counselling (MC)"
                }
            ]
        }
    ],
    "serviceType": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/service-type-my-core",
                "code": "VCI",
                "display": "Individual Virtual Consultation"
            }
        ]
    },
    "subject": {
        "reference": "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|PHIS-123"
    },
    "participant":  [
        {
            "type":  [
                {
                    "coding":  [
                        {
                            "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
                            "code": "ATND",
                            "display": "attender"
                        }
                    ]
                }
            ],
            "period": {
                "start": "2022-12-19T12:45:14+08:00"
            },
            "individual": {
                "display": "Primary Attender Practitioner Name"
            }
        }
    ],
    "period": {
        "start": "2022-12-19T12:34:00+08:00",
        "end": "2022-12-19T14:23:08+08:00"
    },
    "diagnosis":  [
        {
            "condition": {
                "display": "Allergic Reaction to Penicillin"
            },
            "use": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/diagnosis-role-my-core",
                        "code": "01",
                        "display": "Main Diagnosis"
                    }
                ]
            }
        },
        {
            "condition": {
                "display": "Asthma"
            },
            "use": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/diagnosis-role-my-core",
                        "code": "08",
                        "display": "Other Diagnosis"
                    }
                ]
            }
        }
    ],
    "serviceProvider": {
        "reference": "Organization/11-05060009"
    }
}

API

Operation	Address	Request Method	Example
Create Record	[base]/Encounter/@FacilityRnIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Encounter/HTJ-PHIS-ENC-123
Update Record	[base]/Encounter/@FacilityRnIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Encounter/HTJ-PHIS-ENC-123
Read Record	[base]/Encounter/@FacilityRnIdentifier	GET	https://fhir.hie.moh.gov.my/baseR4/Encounter/HTJ-PHIS-ENC-123

Mapping

HIE Item	Element Description	Cardinality	ValueSet/Remark	FHIR Element	FHIR Elemet DataType
Profile	Profiles this resource claims to conform to	1..1	http://fhir.hie.moh.gov.my/StructureDefinition/Encounter-my-core	Encounter.meta.profile	Canonical
Encounter Details
Identifier	Identifier(s) by which this encounter is known	1..1		Encounter.identifier.value where system=http://fhir.hie.moh.gov.my/sid/encounter-id	String
Latest Status	Current state of the encounter.	1..1	ValueSetEncounterStatus (MY Core)	Encounter.status	Code
Latest Status Start Date	Start period of current status	1..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Encounter.period.start	DateTime
Latest Status End Date	End period of current status	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Encounter.period.end	DateTime
StatusHistory	Past state of the encounter.	0..*	ValueSetEncounterStatus (MY Core)	Encounter.statusHistory.status	Code
StatusHistory Start Date	Start period of past status	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Encounter.statusHistory.status.period.start	DateTime
StatusHistory End Date	End period of past status	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Encounter.statusHistory.status.period.end	DateTime
Encounter Type	Classification of the encounter.	1..1	ValueSetEncounterClass (MY Core)	Encounter.class.code	Coding
ServiceType	Broad categorization of the service that is to be provided.	1..1	ValueSetServiceType (MY Core)	Encounter.serviceType.coding.code	CodeableConcept
Service	The type of encounter.	1..1	ValueSetSpecialty (MY Core)	Encounter.type.coding.code	CodeableConcept
Subject	The patient or group present at the encounter	1..1	Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	Encounter.subject.reference	Reference
Primary Attender	Primary attender to this encounter	0..1		Encounter.participant.individual.display where Encounter.type.coding.code=ATND	String
Primary Attender Attended Date	Start time of primary attender	0..1		Encounter.participant.period.start	DateTime
Diagnosis	The list of diagnosis relevant to this encounter	0..*		Encounter.diagnosis.condition.display	String
Diagnosis Role	The type of diagnosis this condition represents.	1..1 if Diagnosis specified	ValueSetDiagnosisRole (My Core)	Encounter.diagnosis.use.coding.code	CodeableConcept
Service Provider	The organization (facility) responsible for this encounter	1..1	Reference facility related by "Organization/@OrganizationPikId"	Encounter.serviceProvider.reference	Reference
Audit
Recorder	Practitioner who first recorded this encounter	0..1		Patient.extension.audit.recorder.valueReference.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=recorder	String
Recorded Date	Date encounter was first recorded	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Patient.extension.audit.recordedDate.valueDateTime.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=recordedDate	DateTime
Updator	Practitioner who last updated this encounter	0..1		Patient.extension.audit.lastUpdater.valueReference.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=lastUpdater	String
Last Updated	Last encounter updated date	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Patient.meta.lastUpdated	DateTime (SystemGenerated)

Allergy

Scenario: PhIS will send allergy record to HIE

Related Profile: AllergyIntolerance (MY Core)

Example JSON

Command 'json' could not render: File was not found for example-allergy-phis

API

Operation	Address	Request Method	Example
Create Record	[base]/AllergyIntolerance/@FacilityAllergyIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123
Update Record	[base]/AllergyIntolerance/@FacilityAllergyIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123
Read Record	[base]/AllergyIntolerance/@FacilityAllergyIdentifier	GET	https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123

Mapping

HIE Item	Element Description	Cardinality	PHIS Field Name	ValueSet/Remark	FHIR Element	FHIR Elemet DataType
Profile	Profiles this resource claims to conform to	1..1		http://fhir.hie.moh.gov.my/StructureDefinition/AllergyIntolerance-my-core	AllergyIntolerance.meta.profile	Canonical
Allergy Details
Patient	Who the sensitivity is for	1..1		Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	AllergyIntolerance.patient.reference	Reference
Encounter	Encounter when the allergy or intolerance was asserted	0..1		Reference encounter record by "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	AllergyIntolerance.encounter.reference	Reference
Category	Category of the identified substance.	1..1	Allergen Type	AllergyIntoleranceCategory	AllergyIntolerance.category	code
Active Ingredient	Type of the substance/product, allergy or intolerance condition	1..1	Active Ingredient / Non Drug / Drug Allergy (Non MOH)	ValueSetAllergyCode (MY Core)	AllergyIntolerance.code.coding.code	CodeableConcept
Formulary	Whether or not the active ingredient is based on a formulary or not	1..1	Drug Allergy (Non MOH)		AllergyIntolerance.extension.valueBoolean where AllergyIntolerance.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/formulary-boolean-my-core	Boolean
Last Occurrence	Date(/time) of last known occurrence of a reaction	0..1			AllergyIntolerance.lastOccurrence	DateTime
Clinical Status	The clinical status of the allergy or intolerance.	1..1		AllergyIntoleranceClinicalStatusCodes	AllergyIntolerance.clinicalStatus.coding.code	CodeableConcept
Verification Status	"Assertion about certainty associated with the propensity, or potential risk, of a reaction to the identified substance (including pharmaceutical product)."	1..1	Allergy Status	AllergyIntoleranceVerificationStatusCodes	AllergyIntolerance.verificationStatus.coding.code	CodeableConcept
Recorded Date	The recordedDate represents when this particular AllergyIntolerance record was created in the system, which is often a system-generated date.	0..1		FHIR Format YYYY-MM-DDThh:mm:ss+08:00	AllergyIntolerance.recordedDate	DateTime
Last Updated	When the resource version last changed	0..1		FHIR Format YYYY-MM-DDThh:mm:ss+08:00	AllergyIntolerance.meta.lastUpdated	DateTime (System Generated)
Recorder	Who recorded the sensitivity	0..1			AllergyIntolerance.recorder.display	String
Attester	Source of the information about the allergy	0..1			AllergyIntolerance.asserter.display	String
Reaction Details
Substance	Codes defining the type of the substance (including pharmaceutical products).	0..1	Active Ingredient/Non Drug/Drug Allergy (Non MOH)	ValueSetAllergyCode (MY Core)	AllergyIntolerance.substance.coding.code	CodeableConcept
Formulary	Whether or not the substance is based on a formulary or not	1..1			AllergyIntolerance.reaction.extension.valueBoolean where AllergyIntolerance.reaction.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/formulary-boolean-my-core	Boolean
Onset Date	Date(/time) when manifestations showed	1..1			AllergyIntolerance.reaction.onset	DateTime
Brand Name	The brand name if medication	0..1			AllergyIntolerance.reaction.description	String
Severity	Clinical assessment of the severity of the reaction event as a whole, potentially considering multiple different manifestations.	0..1		AllergyIntoleranceSeverity	AllergyIntolerance.reaction.severity	CodeableConcept
Exposure Route	Identification of the route by which the subject was exposed to the substance.	0..1		SNOMEDCTRouteCodes	AllergyIntolerance.reaction.exposureRoute.coding.code	CodeableConcept
Reaction	Adverse Reaction Events linked to exposure to substance	0..*	Reaction Details	ValueSetAllergyManifestation (MY Core)	AllergyIntolerance.reaction.manifestation.coding.code	CodeableConcept
Reaction Note
Reaction Note	Text about event not captured in other fields	0..1			AllergyIntolerance.reaction.note.text	String
Recorder	Individual responsible for the annotation	If Reaction Note exist 0..1, else 0..0			AllergyIntolerance.reaction.note.authorReference.display	String
Recorded Date	When the annotation was made	If Reaction Note exist 0..1, else 0..0			AllergyIntolerance.reaction.note.time	DateTime

Allergy Status

FHIR seperates allergy status into clinical allergy.clinicalStatus and verification status.verificationStatus where PhIS only has 1 status field.
These are the agreed status mapping between PhIS and HIE

PhIS Status	ClinicalStatus	VerificationStatus
suspected	active	unconfirmed
active	active	confirmed
unconfirmed	resolved	confirmed

Allergy Negation Statement

Scenario: PhIS will send allergy negation statement to HIE

Related Profile: AllergyIntoleranceNegation (MY Core)

Example JSON

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API

Operation	Address	Request Method	Example
Create Record	[base]/AllergyIntolerance/@FacilityAllergyIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123
Update Record	[base]/AllergyIntolerance/@FacilityAllergyIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123
Read Record	[base]/AllergyIntolerance/@FacilityAllergyIdentifier	GET	https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123

Mapping

HIE Item	Element Description	Cardinality	ValueSet/Remark	FHIR Element	FHIR Elemet DataType
Profile	Profiles this resource claims to conform to	1..1	http://fhir.hie.moh.gov.my/StructureDefinition/AllergyIntolerance-negation-my-core	AllergyIntolerance.meta.profile	Canonical
Allergy Details
Patient	Who the negation statement is for	1..1	Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	AllergyIntolerance.patient.reference	Reference
Encounter	Encounter when the allergy or intolerance was asserted	0..1	Reference encounter record by "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	AllergyIntolerance.encounter.reference	Reference
Negation Statement	Type of the substance/product, allergy or intolerance condition	1..1	ValueSetAllergyNegation (MY Core)	AllergyIntolerance.code.coding.code	CodeableConcept
Clinical Status	The clinical status of the allergy or intolerance.	1..1	AllergyIntoleranceSeverity	AllergyIntolerance.clinicalStatus.coding.code	CodeableConcept
Recorded Date	The recordedDate represents when this particular AllergyIntolerance record was created in the system, which is often a system-generated date.	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	AllergyIntolerance.recordedDate	DateTime
Recorder	Who recorded this negation statement	0..1		AllergyIntolerance.recorder.display	String
Attester	who attested to this negation statement	0..1		AllergyIntolerance.asserter.display	String

MTAC summary

Scenario: PhIS will send MTAC summary to HIE

Related Profile: Composition (MY Core)

Example JSON

{
    "resourceType": "Composition",
    "id": "HTJ-PHIS-MTAC-123",
    "meta": {
        "source": "http://phis.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core"
        ]
    },
    "identifier": {
        "system": "http://fhir.hie.moh.gov.my/sid/composition-id",
        "value": "HTJ-PHIS-MTAC-123"
    },
    "status": "final",
    "type": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-type-my-core",
                "code": "34821-9",
                "display": "Pharmacology Note"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core",
                    "code": "LP173418-7",
                    "display": "Note"
                }
            ]
        }
    ],
    "confidentiality": "N",
    "subject": {
        "reference": "Patient/Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|PHIS-123"
    },
    "encounter": {
        "reference": "Encounter/Encounter?identifier=http://fhir.hie.moh.gov.my/sid/encounter-id|PHIS-ENC-2212000101"
    },
    "date": "2022-09-29T12:13:00+08:00",
    "author":  [
        {
            "display": "Recorder Practitioner Name"
        }
    ],
    "title": "Note",
    "custodian": {
        "reference": "Organization/11-05060009",
        "display": "HOSPITAL TUANKU JA'AFAR"
    },
    "event":  [
        {
            "code":  [
                {
                    "coding":  [
                        {
                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core",
                            "code": "0002-0001",
                            "display": "MTAC (Medical therapy adherance clinic)"
                        }
                    ]
                }
            ],
            "period": {
                "start": "2022-09-29T12:13:00+08:00"
            }
        }
    ],
    "section":  [
        {
            "title": "Clinical Information",
            "code": {
                "coding":  [
                    {
                        "system": "http://loinc.org",
                        "code": "55752-0",
                        "display": "Clinical Information"
                    }
                ]
            },
            "text": {
                "status": "generated",
                "div": " <div xmlns=\"http://www.w3.org/1999/xhtml\"> <p> <b>1. Facility Information</b> </p> <p>Facility name &amp; ID: (Remarks) </p><br/> <p> <b>2. Patient Information</b> </p> <p>Patient identification: (Remarks) </p> <p><br/> <b>3. MTAC Order</b> </p> <p>Virtual Session: (Remarks)</p> <p>Type of MTAC: (Remarks)</p> <p>Appointment Date: (Remarks)</p> <p>Appointment Type: (Remarks) </p> <p><br/> <b>4. MTAC Reporting</b> </p> <p>Understanding: (Remarks)</p> <p>MTAC Status: (Remarks) </p></div>"
            }
        }
    ]
}

API

Operation	Address	Request Method	Example
Create Record	[base]/Composition/@FacilityCompositionIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MTAC-123
Update Record	[base]/Composition/@FacilityCompositionIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MTAC-123
Read Record	[base]/Composition/@FacilityCompositionIdentifier	GET	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MTAC-123

Mapping

HIE Item	Element Description	Cardinality	ValueSet/Remark	FHIR Element	FHIR Elemet DataType
Profile	Profiles this resource claims to conform to	1..1	http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core	Composition.meta.profile	Canonical
Composition Details
Category	High-level kind of a clinical document at a macro level.	1..1	ValueSetCompositionCategory (MY Core)	Composition.category.coding.code=LP173418-7	CodeableConcept
Type	Type of a composition.	1..1	ValueSetCompositionType (MY Core)	Composition.type.coding.code=34821-9	CodeableConcept
Event	The clinical service(s) being documented	1..1	ValueSetCompositionEvent (MY Core)	Composition.event.coding.code=0002-0001	CodeableConcept
Status	The workflow/clinical status of the composition.	1..1	CompositionStatus	Composition.status	CodeableConcept
Subject	Who and/or what the composition is about	1..1	Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	Composition.subject.reference	Reference
Encounter	The clinical encounter or type of care this documentation is associated with.	0..1	Reference encounter record by "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	Composition.encounter.reference	Reference
Recorder Date	Composition editing time	1..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Composition.date	DateTime
Event Date	The period covered by the documentation	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Composition.event.period.start	DateTime
Recorder	Who and/or what authored the composition	0..1		Composition.author.display	String
Facility	Organization which maintains the composition	0..1	Reference facility related by "Organization/@OrganizationPikId"	Composition.custodian.reference	Reference
Entry
Section	The root of the sections that make up the composition.	1..1	Hardcode as 55752-0	Composition.section.code.coding.code	CodeableConcept
Entry	Text summary of the section, for human interpretation	1..1	Refer JSON for MTAC content	Composition.section.text.div where Composition.section.code.coding.code=55752-0	HTML entry field

MC summary

Scenario: PhIS will send MC summary to HIE

Related Profile: Composition (MY Core)

Example JSON

{
    "resourceType": "Composition",
    "id": "HTJ-PHIS-MC-123",
    "meta": {
        "source": "http://phis.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core"
        ]
    },
    "identifier": {
        "system": "http://fhir.hie.moh.gov.my/sid/composition-id",
        "value": "HTJ-PHIS-MC-123"
    },
    "status": "final",
    "type": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-type-my-core",
                "code": "34821-9",
                "display": "Pharmacology Note"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core",
                    "code": "LP173418-7",
                    "display": "Note"
                }
            ]
        }
    ],
    "confidentiality": "N",
    "subject": {
        "reference": "Patient/Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|PHIS-123"
    },
    "encounter": {
        "reference": "Encounter/Encounter?identifier=http://fhir.hie.moh.gov.my/sid/encounter-id|PHIS-ENC-2212000101"
    },
    "date": "2022-09-29T12:13:00+08:00",
    "author":  [
        {
            "display": "Recorder Practitioner Name"
        }
    ],
    "title": "Note",
    "custodian": {
        "reference": "Organization/11-05060009",
        "display": "HOSPITAL TUANKU JA'AFAR"
    },
    "event":  [
        {
            "code":  [
                {
                    "coding":  [
                        {
                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core",
                            "code": "0002-0002",
                            "display": "MC (Medication Counselling)"
                        }
                    ]
                }
            ],
            "period": {
                "start": "2022-09-29T12:13:00+08:00"
            }
        }
    ],
    "section":  [
        {
            "title": "Clinical Information",
            "code": {
                "coding":  [
                    {
                        "system": "http://loinc.org",
                        "code": "55752-0",
                        "display": "Clinical Information"
                    }
                ]
            },
            "text": {
                "status": "generated",
                "div": " <div xmlns=\"http://www.w3.org/1999/xhtml\"> <p> <b>1. Facility Information</b> </p> <p>Facility name &amp; ID: (Remarks) </p> <br /> <p> <b>2. Patient Information</b> </p> <p>Patient identification: (Remarks) </p> <br /> <p> <b>3. Individual Medication Counseling (Medication Counseling Order)</b> </p> <p>Virtual Session: (Remarks)</p> <p>Appointment Date: (Remarks)</p> <p>Appointment Type: (Remarks)</p> <p>Counselling Type: (Remarks) </p> <p>HMR Type: (Remarks) </p> <p>Counselling Topics: (Remarks) </p> <p>Counselling Sub-topic: (Remarks) </p> <br /> <p> <b>4. Medication Counseling Reporting</b> </p> <p>Understanding: (Remarks)</p> <p>Follow up required: (Remarks) </p></div>"
            }
        }
    ]
}

API

Operation	Address	Request Method	Example
Create Record	[base]/Composition/@FacilityCompositionIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MC-123
Update Record	[base]/Composition/@FacilityCompositionIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MC-123
Read Record	[base]/Composition/@FacilityCompositionIdentifier	GET	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MC-123

Mapping

HIE Item	Element Description	Cardinality	ValueSet/Remark	FHIR Element	FHIR Elemet DataType
Profile	Profiles this resource claims to conform to	1..1	http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core	Composition.meta.profile	Canonical
Composition Details
Category	High-level kind of a clinical document at a macro level.	1..1	ValueSetCompositionCategory (MY Core)	Composition.category.coding.code=LP173418-7	CodeableConcept
Type	Type of a composition.	1..1	ValueSetCompositionType (MY Core)	Composition.type.coding.code=34821-9	CodeableConcept
Event	The clinical service(s) being documented	1..1	ValueSetCompositionEvent (MY Core)	Composition.event.coding.code=0002-0002	CodeableConcept
Status	The workflow/clinical status of the composition.	1..1	CompositionStatus	Composition.status	CodeableConcept
Subject	Who and/or what the composition is about	1..1	Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	Composition.subject.reference	Reference
Encounter	The clinical encounter or type of care this documentation is associated with.	0..1	Reference encounter record by "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	Composition.encounter.reference	Reference
Recorder Date	Composition editing time	1..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Composition.date	DateTime
Event Date	The period covered by the documentation	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Composition.event.period.start	DateTime
Recorder	Who and/or what authored the composition	0..1		Composition.author.display	String
Facility	Organization which maintains the composition	0..1	Reference facility related by "Organization/@OrganizationPikId"	Composition.custodian.reference	Reference
Entry
Section	The root of the sections that make up the composition.	1..1	Hardcode as 55752-0	Composition.section.code.coding.code	CodeableConcept
Entry	Text summary of the section, for human interpretation	1..1	Refer JSON for MTAC content	Composition.section.text.div where Composition.section.code.coding.code=55752-0	HTML entry field

ADR report

Scenario: PhIS will send ADR report to HIE

Related Profile: Composition (MY Core)

Example JSON

{
    "resourceType": "Composition",
    "id": "HTJ-PHIS-ADR-123",
    "meta": {
        "source": "http://phis.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core"
        ]
    },
    "identifier": {
        "system": "http://fhir.hie.moh.gov.my/sid/composition-id",
        "value": "HTJ-PHIS-ADR-123"
    },
    "status": "final",
    "type": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-type-my-core",
                "code": "34821-9",
                "display": "Pharmacology Note"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core",
                    "code": "LP173418-7",
                    "display": "Note"
                }
            ]
        }
    ],
    "confidentiality": "N",
    "subject": {
        "reference": "Patient/Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|PHIS-123"
    },
    "encounter": {
        "reference": "Encounter/Encounter?identifier=http://fhir.hie.moh.gov.my/sid/encounter-id|PHIS-ENC-2212000101"
    },
    "date": "2022-09-29T12:13:00+08:00",
    "author":  [
        {
            "display": "Recorder Practitioner Name"
        }
    ],
    "title": "Note",
    "custodian": {
        "reference": "Organization/11-05060009",
        "display": "HOSPITAL TUANKU JA'AFAR"
    },
    "event":  [
        {
            "code":  [
                {
                    "coding":  [
                        {
                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core",
                            "code": "0002-0003",
                            "display": "ADR (Adverse Drug Event)"
                        }
                    ]
                }
            ],
            "period": {
                "start": "2022-09-29T12:13:00+08:00"
            }
        }
    ],
    "section":  [
        {
            "title": "Clinical Information",
            "code": {
                "coding":  [
                    {
                        "system": "http://loinc.org",
                        "code": "55752-0",
                        "display": "Clinical Information"
                    }
                ]
            },
            "text": {
                "status": "generated",
                "div": " <div xmlns=\"http://www.w3.org/1999/xhtml\"> <p> <b>1. Facility Information</b> </p> <p>Facility name &amp; ID: (Remarks) </p><br/> <p> <b>2. Patient Information</b> </p> <p>Patient identification: (Remarks) </p><br/> <p> <b>3. Adverse Reaction Description</b> </p> <p>a) Adverse Reaction Description: (Remarks)</p> <p>b) Time to Onset of Reaction (1): (Remarks)</p> <p>b) Time to Onset of Reaction (2): (Remarks)</p> <p>c) Reaction subsided after action taken with suspected drug: (Remarks) </p> <p>d) Reaction reappeared after reintroducing suspected drug: (Remarks) </p> <p>e) Outcome (Remarks) </p><br/> <p> <b>4. Suspected Drug</b> </p> <p>MDC: (Remarks)</p> <p>Product/Generic Name: (Remarks)</p> <p>Drug Type: (Remarks)</p> <p>Dose: (Remarks)</p> <p>Route: (Remarks)</p> <p>Manufacturer: (Remarks)</p> <p>Product Reg No.: (Remarks)</p> <p>Brand: (Remarks)</p> <p>Therapy Start Date: (Remarks)</p> <p>Therapy End Date: (Remarks)</p> <p>Therapy End Date Remark: (Remarks)</p> <p>Indication: (Remarks)</p></div>"
            }
        }
    ]
}

API

Operation	Address	Request Method	Example
Create Record	[base]/Encounter/@FacilityRnIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-ADR-123
Update Record	[base]/Encounter/@FacilityRnIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-ADR-123
Read Record	[base]/Encounter/@FacilityRnIdentifier	GET	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-ADR-123

Mapping

HIE Item	Element Description	Cardinality	ValueSet/Remark	FHIR Element	FHIR Elemet DataType
Profile	Profiles this resource claims to conform to	1..1	http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core	Composition.meta.profile	Canonical
Composition Details
Category	High-level kind of a clinical document at a macro level.	1..1	ValueSetCompositionCategory (MY Core)	Composition.category.coding.code=LP173418-7	CodeableConcept
Type	Type of a composition.	1..1	ValueSetCompositionType (MY Core)	Composition.type.coding.code=34821-9	CodeableConcept
Event	The clinical service(s) being documented	1..1	ValueSetCompositionEvent (MY Core)	Composition.event.code.coding.code=0002-0003	CodeableConcept
Status	The workflow/clinical status of the composition.	1..1	CompositionStatus	Composition.event.code.coding.code	CodeableConcept
Subject	Who and/or what the composition is about	1..1	Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	Composition.subject.reference	Reference
Encounter	The clinical encounter or type of care this documentation is associated with.	0..1	Reference encounter record by "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	Composition.encounter.reference	Reference
Recorder Date	Composition editing time	1..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Composition.date	DateTime
Event Date	The period covered by the documentation	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Composition.event.period.start	DateTime
Recorder	Who and/or what authored the composition	0..1		Composition.author.display	String
Facility	Organization which maintains the composition	0..1	Reference facility related by "Organization/@OrganizationPikId"	Composition.custodian.reference	Reference
Entry
Section	The root of the sections that make up the composition.	1..1	Hardcode as 55752-0	Composition.section.code.coding.code	CodeableConcept
Entry	"Text summary of the section, for human interpretation"	1..1	Refer JSON for MTAC content	Composition.section.text.div where Composition.section.code.coding.code=55752-0	HTML entry field

Master Drug List

Scenario: HIE will retrieve drug master list from PhIS IWP API

Related Profile: MedicationKnowledge (MY Core)

Example JSON

{
    "resourceType": "MedicationKnowledge",
    "id": "N02BE01000T1001XX",
    "meta": {
        "source": "http://provider.hie.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/MedicationKnowledge-my-core"
        ]
    },
    "extension":  [
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core",
            "extension":  [
                {
                    "url": "recorder",
                    "valueReference": {
                        "display": "Recorder Practitioner name"
                    }
                },
                {
                    "url": "recordedDate",
                    "valueDateTime": "2022-08-15T14:48:27+08:00"
                },
                {
                    "url": "lastUpdater",
                    "valueReference": {
                        "display": "Last updater Practitioner name"
                    }
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "N02BE01000T1001XX",
                "display": "Paracetamol 500 mg Tablet"
            }
        ],
        "text": "Paracetamol 500mg Tab"
    },
    "status": "active",
    "doseForm": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-dose-form-my-core",
                "code": "270",
                "display": "Oral Tablet"
            }
        ]
    },
    "synonym":  [
        "N/A"
    ],
    "productType":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-type-my-core",
                    "code": "PN",
                    "display": "PN"
                }
            ]
        }
    ],
    "ingredient":  [
        {
            "itemCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/active-ingredient-my-core",
                        "code": "410",
                        "display": "Amino acid+ dextrose+ lipid+ electrolytes"
                    }
                ],
                "text": "Amino acid+ dextrose+ lipid+ electrolytes"
            },
            "strength": {
                "numerator": {
                    "value": 500,
                    "unit": "mg",
                    "system": "http://unitsofmeasure.org",
                    "code": "mg"
                },
                "denominator": {
                    "value": 1,
                    "unit": "tablet",
                    "system": "http://unitsofmeasure.org",
                    "code": "tablet"
                }
            }
        }
    ],
    "administrationGuidelines":  [
        {
            "dosage":  [
                {
                    "type": {
                        "coding":  [
                            {
                                "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-sub-group-my-core",
                                "code": "70",
                                "display": "Parenteral Nutrition"
                            }
                        ]
                    },
                    "dosage":  [
                        {
                            "additionalInstruction":  [
                                {
                                    "coding":  [
                                        {
                                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-special-instruction-my-core",
                                            "code": "10",
                                            "display": "Administer 15-30 minutes before _____"
                                        }
                                    ],
                                    "text": "Administer 15-30 minutes before _____"
                                },
                                {
                                    "coding":  [
                                        {
                                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-cautionary-my-core",
                                            "code": "60",
                                            "display": "Avoid contact with eyes"
                                        }
                                    ],
                                    "text": "Avoid contact with eyes"
                                }
                            ],
                            "patientInstruction": "Apply as directed",
                            "timing": {
                                "code": {
                                    "coding":  [
                                        {
                                            "system": "http://terminology.hl7.org/CodeSystem/v3-GTSAbbreviation",
                                            "code": "BID",
                                            "display": "BID"
                                        }
                                    ]
                                }
                            },
                            "route": {
                                "coding":  [
                                    {
                                        "system": "http://snomed.info/sct",
                                        "code": "26643006",
                                        "display": "Oral route"
                                    }
                                ]
                            },
                            "doseAndRate":  [
                                {
                                    "doseQuantity": {
                                        "value": 500,
                                        "unit": "mg",
                                        "system": "http://unitsofmeasure.org",
                                        "code": "mg"
                                    }
                                }
                            ]
                        }
                    ]
                }
            ]
        }
    ],
    "medicineClassification":  [
        {
            "extension":  [
                {
                    "url": "http://fhir.hie.moh.gov.my/StructureDefinition/formulary-boolean-my-core",
                    "valueBoolean": true
                }
            ],
            "type": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-sub-group-my-core",
                        "code": "70",
                        "display": "Parenteral Nutrition"
                    }
                ]
            },
            "classification":  [
                {
                    "coding":  [
                        {
                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-category-my-core",
                            "code": "B",
                            "display": "B"
                        }
                    ]
                }
            ]
        }
    ],
    "regulatory":  [
        {
            "regulatoryAuthority": {
                "display": "placeholder"
            },
            "schedule":  [
                {
                    "schedule": {
                        "coding":  [
                            {
                                "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-schedule-my-core",
                                "code": "SP",
                                "display": "Schedule Poison"
                            }
                        ]
                    }
                }
            ]
        }
    ]
}

Facility Drug List

Scenario: HIE will retrieve drug master list from PhIS IWP API

Related Profile: Medication (MY Core)

Example JSON

{
    "resourceType": "Medication",
    "id": "example-medication",
    "meta": {
        "versionId": "10",
        "lastUpdated": "2022-08-22T08:29:46.670+08:00",
        "source": "http://provider.hie.moh.gov.my#luMHDWniHDEi418A",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Medication-my-core"
        ]
    },
    "extension":  [
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core",
            "extension":  [
                {
                    "url": "recorder",
                    "valueReference": {
                        "reference": "PractitionerRole/8c99c924-ba17-47aa-8bf1-b88cf0e68b61/_history/1",
                        "display": "HASAN"
                    }
                },
                {
                    "url": "recordedDate",
                    "valueDateTime": "2022-08-15T14:48:27+08:00"
                },
                {
                    "url": "lastUpdater",
                    "valueReference": {
                        "reference": "HASAN",
                        "display": "PractitionerRole/8c99c924-ba17-47aa-8bf1-b88cf0e68b61/_history/1"
                    }
                }
            ]
        },
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/service-provider-my-core",
            "valueReference": {
                "reference": "Organization/11-05060009"
            }
        },
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/medication-knowledge-my-core",
            "valueReference": {
                "reference": "MedicationKnowledge/N02BE01000T1001XX"
            }
        }
    ],
    "code": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-my-core",
                "code": "N02BE01000T1001XX",
                "display": "Paracetamol 500 mg Tablet"
            }
        ],
        "text": "Paracetamol 500mg Tab"
    },
    "status": "active"
}

Integration Point

Back to Overview

Patient Registration

Scenario: PhIS will send patient record to HIE

Related Profile: Patient (MY Core)

Example JSON

{
    "resourceType": "Patient",
    "id": "example-patient-phis",
    "meta": {
        "versionId": "4",
        "lastUpdated": "2022-12-19T06:54:52.308+08:00",
        "source": "http://phis.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Patient-my-core"
        ]
    },
    "extension":  [
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core",
            "extension":  [
                {
                    "url": "recorder",
                    "valueReference": {
                        "display": "First Recorder Practitioner Name"
                    }
                },
                {
                    "url": "recordedDate",
                    "valueDateTime": "2022-12-19T12:34:00+08:00"
                },
                {
                    "url": "lastUpdater",
                    "valueReference": {
                        "display": "Last Updater Practitioner Name"
                    }
                }
            ]
        },
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/education-level-my-core",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/education-level-my-core",
                        "code": "4",
                        "display": "tertiary"
                    }
                ]
            }
        },
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/religion-my-core",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/religion-my-core",
                        "code": "1",
                        "display": "Islam"
                    }
                ]
            }
        },
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/ethnic-my-core",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/ethnic-my-core",
                        "code": "01",
                        "display": "Melayu"
                    }
                ]
            }
        }
    ],
    "identifier":  [
        {
            "system": "http://fhir.hie.moh.gov.my/sid/my-kad-no",
            "value": "921005141234"
        },
        {
            "system": "http://fhir.hie.moh.gov.my/sid/patient-mrn",
            "value": "PHIS-123"
        }
    ],
    "active": true,
    "name":  [
        {
            "extension":  [
                {
                    "url": "http://fhir.hie.moh.gov.my/StructureDefinition/person-title-my-core",
                    "valueCodeableConcept": {
                        "coding":  [
                            {
                                "system": "http://fhir.hie.moh.gov.my/CodeSystem/person-title-my-core",
                                "code": "L001",
                                "display": "Encik"
                            }
                        ]
                    }
                }
            ],
            "given":  [
                "PHIS patient name example"
            ]
        }
    ],
    "telecom":  [
        {
            "system": "phone",
            "value": "014454120315"
        },
        {
            "system": "email",
            "value": "hieperson@gmail.com"
        }
    ],
    "gender": "male",
    "birthDate": "1992-10-05",
    "deceasedBoolean": false,
    "address":  [
        {
            "extension":  [
                {
                    "url": "http://fhir.hie.moh.gov.my/StructureDefinition/address-district-my-core",
                    "valueCodeableConcept": {
                        "coding":  [
                            {
                                "system": "http://fhir.hie.moh.gov.my/CodeSystem/district-my-core",
                                "code": "0505",
                                "display": "Seremban"
                            }
                        ]
                    }
                },
                {
                    "url": "http://fhir.hie.moh.gov.my/StructureDefinition/address-state-my-core",
                    "valueCodeableConcept": {
                        "coding":  [
                            {
                                "system": "http://fhir.hie.moh.gov.my/CodeSystem/state-my-core",
                                "code": "05",
                                "display": "Negeri Sembilan"
                            }
                        ]
                    }
                }
            ],
            "use": "home",
            "line":  [
                "No. 1, Jalan Bangsar 7/3"
            ],
            "city": "Laman Pelangi",
            "postalCode": "02196",
            "country": "MYS"
        }
    ],
    "contact":  [
        {
            "name": {
                "given":  [
                    "PHIS contact name example"
                ]
            },
            "telecom":  [
                {
                    "system": "phone",
                    "value": "01527893031",
                    "use": "mobile"
                }
            ],
            "gender": "male"
        }
    ],
    "managingOrganization": {
        "reference": "Organization/PHIS",
        "display": "Pharmacy Information System (PhIS)"
    }
}

API

Operation	Address	Request Method	Example
Create Record	[base]/Patient/@FacilityMrnIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Patient/HTJ-PHIS-123
Update Record	[base]/Patient/@FacilityMrnIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Patient/HTJ-PHIS-123
Read Record	[base]/Patient/@FacilityMrnIdentifier	GET	https://fhir.hie.moh.gov.my/baseR4/Patient/HTJ-PHIS-123

Mapping

HIE Item	Element Description	Cardinality	ValueSet/Remark	FHIR Element	FHIR Elemet DataType
Profile	Profiles this resource claims to conform to	1..1	http://fhir.hie.moh.gov.my/StructureDefinition/Patient-my-core	Patient.meta.profile	Canonical
Patient Details
Identification (My Kad)	My Kad no identifier	0..1	At least 1 identifier	Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/my-kad-no	String
Identification (Passport)	Passport no identifier	0..1	At least 1 identifier	Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/passport-no	String
Identification (Army)	Army no identifier	0..1	At least 1 identifier	Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/army-no	String
Identification (Police)	Police no identifier	0..1	At least 1 identifier	Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/police-no	String
Identification (MRN no)	MRN no identifier	1..1	MRN mandatory from source system	Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/patient-mrn	String
Identification (Other)	Other no identifier	0..1	At least 1 identifier	Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/others-no	String
Identification (Unknown)	Unknown no identifier	0..1	At least 1 identifier	Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/unknown-no	String
Child	Whether or not this record is a child record	1..1 If Identification (Newborn) value exist, else 0..1		Patient.identifier.extension.extension.valueBoolean where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/child-identification-my-core and Patient.extension.extension.url=child	Boolean
ChildType	Which guardian is child using identifier (mother/father/guardian)	1..1 If Identification (Newborn) value exist, else 0..1	ValueSetChildIdentificationType (MY Core)	Patient.identifier.extension.extension.valueCodeableConcept where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/child-identification-my-core and Patient.extension.extension.url=childType	CodeableConcept
ChildNo	Child number	0..1		Patient.identifier.extension.extension.valueQuantity where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/child-identification-my-core and Patient.extension.extension.url=childNo	Integer
Parent No (Mother ID)	Guardian no identifier	1..1 If Identification (Newborn) value exist, else 0..1		Patient.identifier.extension.extension.valueString where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/child-identification-my-core and Patient.extension.extension.url=parentIdentification	String
Title	Title given to patient	1..1	ValueSetPersonTitle (MY Core)	Patient.name.extension.valueCodeableConcept.coding.code where system=http://fhir.hie.moh.gov.my/StructureDefinition/person-title-my-core
Name	Given name.	1..1		Patient.name.given	String
Gender	The gender of a person used for administrative purposes.	1..1	ValueSetAdministrativeGender (MY Core)	Patient.gender	Code
Birth Date	The date of birth for the individual	1..1	FHIR Format YYYY-MM-DD	Patient.birthDate	Date
Ethnic	Ethnic of individual	0..1	ValueSetEthnic (MY Core)	Patient.extension.valueCodeableConcept.coding.code where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/ethnic-my-core	CodeableConcept
Religion	Religion of individual	0..1	ValueSetReligion (MY Core)	Patient.extension.valueCodeableConcept.coding.code where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/religion-my-core	CodeableConcept
Education Level	Education level of individual	0..1	ValueSetEducationLevel (MY Core)	Patient.extension.valueCodeableConcept.coding.code where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/education-level-my-core	CodeableConcept
Phone Number	Phone number of individual	0..*		Patient.telecom.value where Patient.telecom.system=phone	String
Email Address	Email number of indivdual	0..1		Patient.telecom.value where Patient.telecom.system=email	String
Deceased Status	Indicates if the individual is deceased or not	0..1		Patient.deceasedBoolean	Boolean
Status	Whether this patient's record is in active use	0..1		Patient.active	Boolean
Source System	Source System that is the custodian of the patient record	1..1	Hardcode value as "Organization/PHIS"	Patient.managingOrganization.reference	Reference
Address
Line	Street name, number, direction & P.O. Box etc.	0..1		Patient.address.line	String
Postal Code	Postal code for area	0..1		Patient.address.postalCode	String
Country	Country - a nation as commonly understood or generally accepted.	0..1		Patient.country	String
State	Sub-unit of country	0..1	ValueSetState (MY Core)	Patient.address.extension.valueCodeableConcept.coding.code where Patient.address.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/address-state-my-core	CodeableConcept
District	District name	0..1	ValueSetDistrict (MY Core)	Patient.address.extension.valueCodeableConcept.coding.code where Patient.address.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/address-district-my-core	CodeableConcept
City	Name of city, town etc.	0..1		Patient.address.city	String
Contact (Next of Kin)
Name	A name associated with the contact person.	0..1		Patient.contact.name.given	String
Gender	The gender of a person used for administrative purposes.	0..1	ValueSetAdministrativeGender (MY Core)	Patient.contact.gender	Code
Phone Number	Phone number of contact person	0..1		Patient.contact.telecom.value where Patient.contact.telecom.system=phone	String
Email Address	Email number of contact person	0..1		Patient.contact.telecom.value where Patient.contact.telecom.system=email	String
Contact Address
Line	Street name, number, direction & P.O. Box etc.	0..1		Patient.contact.address.line	String
Postal Code	Postal code for area	0..1		Patient.contact.address.postalCode	String
Country	Country - a nation as commonly understood or generally accepted.	0..1		Patient.contact.country	String
State	Sub-unit of country	0..1	ValueSetState (MY Core)	Patient.contact.address.extension.valueCodeableConcept.coding.code where Patient.address.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/address-state-my-core	CodeableConcept
District	District name	0..1	ValueSetDistrict (MY Core)	Patient.contact.address.extension.valueCodeableConcept.coding.code where Patient.address.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/address-district-my-core	CodeableConcept
City	Name of city, town etc.	0..1		Patient.contact.address.city	String
Audit
Recorder	Practitioner who first recorded this encounter	0..1		Patient.extension.audit.recorder.valueReference.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=recorder	String
Recorded Date	Date encounter was first recorded	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Patient.extension.audit.recordedDate.valueDateTime.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=recordedDate	DateTime
Updator	Practitioner who last updated this encounter	0..1		Patient.extension.audit.lastUpdater.valueReference.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=lastUpdater	String
Last Updated	Last encounter updated date	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Patient.meta.lastUpdated	DateTime (SystemGenerated)

Encounter Registration

Scenario: PhIS will send encounter record to HIE

Related Profile: Encounter (MY Core)

Example JSON

{
    "resourceType": "Encounter",
    "id": "example-encounter-phis",
    "meta": {
        "source": "http://phis.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Encounter-my-core"
        ]
    },
    "extension":  [
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core",
            "extension":  [
                {
                    "url": "recorder",
                    "valueReference": {
                        "display": "First Recorder Practitioner Name"
                    }
                },
                {
                    "url": "recordedDate",
                    "valueDateTime": "2022-12-19T12:34:00+08:00"
                },
                {
                    "url": "lastUpdater",
                    "valueReference": {
                        "display": "Last Updater Practitioner Name"
                    }
                }
            ]
        }
    ],
    "identifier":  [
        {
            "system": "http://fhir.hie.moh.gov.my/sid/encounter-id",
            "value": "PHIS-ENC-2212000101"
        }
    ],
    "status": "finished",
    "statusHistory":  [
        {
            "status": "arrived",
            "period": {
                "start": "2022-12-19T12:34:00+08:00",
                "end": "2022-12-19T12:45:14+08:00"
            }
        },
        {
            "status": "in-progress",
            "period": {
                "start": "2022-12-19T12:45:14+08:00",
                "end": "2022-12-19T14:23:08+08:00"
            }
        }
    ],
    "class": {
        "system": "http://fhir.hie.moh.gov.my/CodeSystem/encounter-class-my-core",
        "code": "VR",
        "display": "Virtual"
    },
    "type":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/specialty-my-core",
                    "code": "543",
                    "display": "Medication Counselling (MC)"
                }
            ]
        }
    ],
    "serviceType": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/service-type-my-core",
                "code": "VCI",
                "display": "Individual Virtual Consultation"
            }
        ]
    },
    "subject": {
        "reference": "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|PHIS-123"
    },
    "participant":  [
        {
            "type":  [
                {
                    "coding":  [
                        {
                            "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
                            "code": "ATND",
                            "display": "attender"
                        }
                    ]
                }
            ],
            "period": {
                "start": "2022-12-19T12:45:14+08:00"
            },
            "individual": {
                "display": "Primary Attender Practitioner Name"
            }
        }
    ],
    "period": {
        "start": "2022-12-19T12:34:00+08:00",
        "end": "2022-12-19T14:23:08+08:00"
    },
    "diagnosis":  [
        {
            "condition": {
                "display": "Allergic Reaction to Penicillin"
            },
            "use": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/diagnosis-role-my-core",
                        "code": "01",
                        "display": "Main Diagnosis"
                    }
                ]
            }
        },
        {
            "condition": {
                "display": "Asthma"
            },
            "use": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/diagnosis-role-my-core",
                        "code": "08",
                        "display": "Other Diagnosis"
                    }
                ]
            }
        }
    ],
    "serviceProvider": {
        "reference": "Organization/11-05060009"
    }
}

API

Operation	Address	Request Method	Example
Create Record	[base]/Encounter/@FacilityRnIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Encounter/HTJ-PHIS-ENC-123
Update Record	[base]/Encounter/@FacilityRnIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Encounter/HTJ-PHIS-ENC-123
Read Record	[base]/Encounter/@FacilityRnIdentifier	GET	https://fhir.hie.moh.gov.my/baseR4/Encounter/HTJ-PHIS-ENC-123

Mapping

HIE Item	Element Description	Cardinality	ValueSet/Remark	FHIR Element	FHIR Elemet DataType
Profile	Profiles this resource claims to conform to	1..1	http://fhir.hie.moh.gov.my/StructureDefinition/Encounter-my-core	Encounter.meta.profile	Canonical
Encounter Details
Identifier	Identifier(s) by which this encounter is known	1..1		Encounter.identifier.value where system=http://fhir.hie.moh.gov.my/sid/encounter-id	String
Latest Status	Current state of the encounter.	1..1	ValueSetEncounterStatus (MY Core)	Encounter.status	Code
Latest Status Start Date	Start period of current status	1..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Encounter.period.start	DateTime
Latest Status End Date	End period of current status	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Encounter.period.end	DateTime
StatusHistory	Past state of the encounter.	0..*	ValueSetEncounterStatus (MY Core)	Encounter.statusHistory.status	Code
StatusHistory Start Date	Start period of past status	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Encounter.statusHistory.status.period.start	DateTime
StatusHistory End Date	End period of past status	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Encounter.statusHistory.status.period.end	DateTime
Encounter Type	Classification of the encounter.	1..1	ValueSetEncounterClass (MY Core)	Encounter.class.code	Coding
ServiceType	Broad categorization of the service that is to be provided.	1..1	ValueSetServiceType (MY Core)	Encounter.serviceType.coding.code	CodeableConcept
Service	The type of encounter.	1..1	ValueSetSpecialty (MY Core)	Encounter.type.coding.code	CodeableConcept
Subject	The patient or group present at the encounter	1..1	Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	Encounter.subject.reference	Reference
Primary Attender	Primary attender to this encounter	0..1		Encounter.participant.individual.display where Encounter.type.coding.code=ATND	String
Primary Attender Attended Date	Start time of primary attender	0..1		Encounter.participant.period.start	DateTime
Diagnosis	The list of diagnosis relevant to this encounter	0..*		Encounter.diagnosis.condition.display	String
Diagnosis Role	The type of diagnosis this condition represents.	1..1 if Diagnosis specified	ValueSetDiagnosisRole (My Core)	Encounter.diagnosis.use.coding.code	CodeableConcept
Service Provider	The organization (facility) responsible for this encounter	1..1	Reference facility related by "Organization/@OrganizationPikId"	Encounter.serviceProvider.reference	Reference
Audit
Recorder	Practitioner who first recorded this encounter	0..1		Patient.extension.audit.recorder.valueReference.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=recorder	String
Recorded Date	Date encounter was first recorded	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Patient.extension.audit.recordedDate.valueDateTime.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=recordedDate	DateTime
Updator	Practitioner who last updated this encounter	0..1		Patient.extension.audit.lastUpdater.valueReference.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=lastUpdater	String
Last Updated	Last encounter updated date	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Patient.meta.lastUpdated	DateTime (SystemGenerated)

Allergy

Scenario: PhIS will send allergy record to HIE

Related Profile: AllergyIntolerance (MY Core)

Example JSON

Command 'json' could not render: File was not found for example-allergy-phis

API

Operation	Address	Request Method	Example
Create Record	[base]/AllergyIntolerance/@FacilityAllergyIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123
Update Record	[base]/AllergyIntolerance/@FacilityAllergyIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123
Read Record	[base]/AllergyIntolerance/@FacilityAllergyIdentifier	GET	https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123

Mapping

HIE Item	Element Description	Cardinality	PHIS Field Name	ValueSet/Remark	FHIR Element	FHIR Elemet DataType
Profile	Profiles this resource claims to conform to	1..1		http://fhir.hie.moh.gov.my/StructureDefinition/AllergyIntolerance-my-core	AllergyIntolerance.meta.profile	Canonical
Allergy Details
Patient	Who the sensitivity is for	1..1		Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	AllergyIntolerance.patient.reference	Reference
Encounter	Encounter when the allergy or intolerance was asserted	0..1		Reference encounter record by "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	AllergyIntolerance.encounter.reference	Reference
Category	Category of the identified substance.	1..1	Allergen Type	AllergyIntoleranceCategory	AllergyIntolerance.category	code
Active Ingredient	Type of the substance/product, allergy or intolerance condition	1..1	Active Ingredient / Non Drug / Drug Allergy (Non MOH)	ValueSetAllergyCode (MY Core)	AllergyIntolerance.code.coding.code	CodeableConcept
Formulary	Whether or not the active ingredient is based on a formulary or not	1..1	Drug Allergy (Non MOH)		AllergyIntolerance.extension.valueBoolean where AllergyIntolerance.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/formulary-boolean-my-core	Boolean
Last Occurrence	Date(/time) of last known occurrence of a reaction	0..1			AllergyIntolerance.lastOccurrence	DateTime
Clinical Status	The clinical status of the allergy or intolerance.	1..1		AllergyIntoleranceClinicalStatusCodes	AllergyIntolerance.clinicalStatus.coding.code	CodeableConcept
Verification Status	"Assertion about certainty associated with the propensity, or potential risk, of a reaction to the identified substance (including pharmaceutical product)."	1..1	Allergy Status	AllergyIntoleranceVerificationStatusCodes	AllergyIntolerance.verificationStatus.coding.code	CodeableConcept
Recorded Date	The recordedDate represents when this particular AllergyIntolerance record was created in the system, which is often a system-generated date.	0..1		FHIR Format YYYY-MM-DDThh:mm:ss+08:00	AllergyIntolerance.recordedDate	DateTime
Last Updated	When the resource version last changed	0..1		FHIR Format YYYY-MM-DDThh:mm:ss+08:00	AllergyIntolerance.meta.lastUpdated	DateTime (System Generated)
Recorder	Who recorded the sensitivity	0..1			AllergyIntolerance.recorder.display	String
Attester	Source of the information about the allergy	0..1			AllergyIntolerance.asserter.display	String
Reaction Details
Substance	Codes defining the type of the substance (including pharmaceutical products).	0..1	Active Ingredient/Non Drug/Drug Allergy (Non MOH)	ValueSetAllergyCode (MY Core)	AllergyIntolerance.substance.coding.code	CodeableConcept
Formulary	Whether or not the substance is based on a formulary or not	1..1			AllergyIntolerance.reaction.extension.valueBoolean where AllergyIntolerance.reaction.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/formulary-boolean-my-core	Boolean
Onset Date	Date(/time) when manifestations showed	1..1			AllergyIntolerance.reaction.onset	DateTime
Brand Name	The brand name if medication	0..1			AllergyIntolerance.reaction.description	String
Severity	Clinical assessment of the severity of the reaction event as a whole, potentially considering multiple different manifestations.	0..1		AllergyIntoleranceSeverity	AllergyIntolerance.reaction.severity	CodeableConcept
Exposure Route	Identification of the route by which the subject was exposed to the substance.	0..1		SNOMEDCTRouteCodes	AllergyIntolerance.reaction.exposureRoute.coding.code	CodeableConcept
Reaction	Adverse Reaction Events linked to exposure to substance	0..*	Reaction Details	ValueSetAllergyManifestation (MY Core)	AllergyIntolerance.reaction.manifestation.coding.code	CodeableConcept
Reaction Note
Reaction Note	Text about event not captured in other fields	0..1			AllergyIntolerance.reaction.note.text	String
Recorder	Individual responsible for the annotation	If Reaction Note exist 0..1, else 0..0			AllergyIntolerance.reaction.note.authorReference.display	String
Recorded Date	When the annotation was made	If Reaction Note exist 0..1, else 0..0			AllergyIntolerance.reaction.note.time	DateTime

Allergy Status

PhIS Status	ClinicalStatus	VerificationStatus
suspected	active	unconfirmed
active	active	confirmed
unconfirmed	resolved	confirmed

Allergy Negation Statement

Scenario: PhIS will send allergy negation statement to HIE

Related Profile: AllergyIntoleranceNegation (MY Core)

Example JSON

Command 'json' could not render: File was not found for example-allergy-negation-phis

API

Operation	Address	Request Method	Example
Create Record	[base]/AllergyIntolerance/@FacilityAllergyIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123
Update Record	[base]/AllergyIntolerance/@FacilityAllergyIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123
Read Record	[base]/AllergyIntolerance/@FacilityAllergyIdentifier	GET	https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123

Mapping

HIE Item	Element Description	Cardinality	ValueSet/Remark	FHIR Element	FHIR Elemet DataType
Profile	Profiles this resource claims to conform to	1..1	http://fhir.hie.moh.gov.my/StructureDefinition/AllergyIntolerance-negation-my-core	AllergyIntolerance.meta.profile	Canonical
Allergy Details
Patient	Who the negation statement is for	1..1	Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	AllergyIntolerance.patient.reference	Reference
Encounter	Encounter when the allergy or intolerance was asserted	0..1	Reference encounter record by "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	AllergyIntolerance.encounter.reference	Reference
Negation Statement	Type of the substance/product, allergy or intolerance condition	1..1	ValueSetAllergyNegation (MY Core)	AllergyIntolerance.code.coding.code	CodeableConcept
Clinical Status	The clinical status of the allergy or intolerance.	1..1	AllergyIntoleranceSeverity	AllergyIntolerance.clinicalStatus.coding.code	CodeableConcept
Recorded Date	The recordedDate represents when this particular AllergyIntolerance record was created in the system, which is often a system-generated date.	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	AllergyIntolerance.recordedDate	DateTime
Recorder	Who recorded this negation statement	0..1		AllergyIntolerance.recorder.display	String
Attester	who attested to this negation statement	0..1		AllergyIntolerance.asserter.display	String

MTAC summary

Scenario: PhIS will send MTAC summary to HIE

Related Profile: Composition (MY Core)

Example JSON

{
    "resourceType": "Composition",
    "id": "HTJ-PHIS-MTAC-123",
    "meta": {
        "source": "http://phis.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core"
        ]
    },
    "identifier": {
        "system": "http://fhir.hie.moh.gov.my/sid/composition-id",
        "value": "HTJ-PHIS-MTAC-123"
    },
    "status": "final",
    "type": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-type-my-core",
                "code": "34821-9",
                "display": "Pharmacology Note"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core",
                    "code": "LP173418-7",
                    "display": "Note"
                }
            ]
        }
    ],
    "confidentiality": "N",
    "subject": {
        "reference": "Patient/Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|PHIS-123"
    },
    "encounter": {
        "reference": "Encounter/Encounter?identifier=http://fhir.hie.moh.gov.my/sid/encounter-id|PHIS-ENC-2212000101"
    },
    "date": "2022-09-29T12:13:00+08:00",
    "author":  [
        {
            "display": "Recorder Practitioner Name"
        }
    ],
    "title": "Note",
    "custodian": {
        "reference": "Organization/11-05060009",
        "display": "HOSPITAL TUANKU JA'AFAR"
    },
    "event":  [
        {
            "code":  [
                {
                    "coding":  [
                        {
                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core",
                            "code": "0002-0001",
                            "display": "MTAC (Medical therapy adherance clinic)"
                        }
                    ]
                }
            ],
            "period": {
                "start": "2022-09-29T12:13:00+08:00"
            }
        }
    ],
    "section":  [
        {
            "title": "Clinical Information",
            "code": {
                "coding":  [
                    {
                        "system": "http://loinc.org",
                        "code": "55752-0",
                        "display": "Clinical Information"
                    }
                ]
            },
            "text": {
                "status": "generated",
                "div": " <div xmlns=\"http://www.w3.org/1999/xhtml\"> <p> <b>1. Facility Information</b> </p> <p>Facility name &amp; ID: (Remarks) </p><br/> <p> <b>2. Patient Information</b> </p> <p>Patient identification: (Remarks) </p> <p><br/> <b>3. MTAC Order</b> </p> <p>Virtual Session: (Remarks)</p> <p>Type of MTAC: (Remarks)</p> <p>Appointment Date: (Remarks)</p> <p>Appointment Type: (Remarks) </p> <p><br/> <b>4. MTAC Reporting</b> </p> <p>Understanding: (Remarks)</p> <p>MTAC Status: (Remarks) </p></div>"
            }
        }
    ]
}

API

Operation	Address	Request Method	Example
Create Record	[base]/Composition/@FacilityCompositionIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MTAC-123
Update Record	[base]/Composition/@FacilityCompositionIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MTAC-123
Read Record	[base]/Composition/@FacilityCompositionIdentifier	GET	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MTAC-123

Mapping

HIE Item	Element Description	Cardinality	ValueSet/Remark	FHIR Element	FHIR Elemet DataType
Profile	Profiles this resource claims to conform to	1..1	http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core	Composition.meta.profile	Canonical
Composition Details
Category	High-level kind of a clinical document at a macro level.	1..1	ValueSetCompositionCategory (MY Core)	Composition.category.coding.code=LP173418-7	CodeableConcept
Type	Type of a composition.	1..1	ValueSetCompositionType (MY Core)	Composition.type.coding.code=34821-9	CodeableConcept
Event	The clinical service(s) being documented	1..1	ValueSetCompositionEvent (MY Core)	Composition.event.coding.code=0002-0001	CodeableConcept
Status	The workflow/clinical status of the composition.	1..1	CompositionStatus	Composition.status	CodeableConcept
Subject	Who and/or what the composition is about	1..1	Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	Composition.subject.reference	Reference
Encounter	The clinical encounter or type of care this documentation is associated with.	0..1	Reference encounter record by "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	Composition.encounter.reference	Reference
Recorder Date	Composition editing time	1..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Composition.date	DateTime
Event Date	The period covered by the documentation	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Composition.event.period.start	DateTime
Recorder	Who and/or what authored the composition	0..1		Composition.author.display	String
Facility	Organization which maintains the composition	0..1	Reference facility related by "Organization/@OrganizationPikId"	Composition.custodian.reference	Reference
Entry
Section	The root of the sections that make up the composition.	1..1	Hardcode as 55752-0	Composition.section.code.coding.code	CodeableConcept
Entry	Text summary of the section, for human interpretation	1..1	Refer JSON for MTAC content	Composition.section.text.div where Composition.section.code.coding.code=55752-0	HTML entry field

MC summary

Scenario: PhIS will send MC summary to HIE

Related Profile: Composition (MY Core)

Example JSON

{
    "resourceType": "Composition",
    "id": "HTJ-PHIS-MC-123",
    "meta": {
        "source": "http://phis.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core"
        ]
    },
    "identifier": {
        "system": "http://fhir.hie.moh.gov.my/sid/composition-id",
        "value": "HTJ-PHIS-MC-123"
    },
    "status": "final",
    "type": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-type-my-core",
                "code": "34821-9",
                "display": "Pharmacology Note"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core",
                    "code": "LP173418-7",
                    "display": "Note"
                }
            ]
        }
    ],
    "confidentiality": "N",
    "subject": {
        "reference": "Patient/Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|PHIS-123"
    },
    "encounter": {
        "reference": "Encounter/Encounter?identifier=http://fhir.hie.moh.gov.my/sid/encounter-id|PHIS-ENC-2212000101"
    },
    "date": "2022-09-29T12:13:00+08:00",
    "author":  [
        {
            "display": "Recorder Practitioner Name"
        }
    ],
    "title": "Note",
    "custodian": {
        "reference": "Organization/11-05060009",
        "display": "HOSPITAL TUANKU JA'AFAR"
    },
    "event":  [
        {
            "code":  [
                {
                    "coding":  [
                        {
                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core",
                            "code": "0002-0002",
                            "display": "MC (Medication Counselling)"
                        }
                    ]
                }
            ],
            "period": {
                "start": "2022-09-29T12:13:00+08:00"
            }
        }
    ],
    "section":  [
        {
            "title": "Clinical Information",
            "code": {
                "coding":  [
                    {
                        "system": "http://loinc.org",
                        "code": "55752-0",
                        "display": "Clinical Information"
                    }
                ]
            },
            "text": {
                "status": "generated",
                "div": " <div xmlns=\"http://www.w3.org/1999/xhtml\"> <p> <b>1. Facility Information</b> </p> <p>Facility name &amp; ID: (Remarks) </p> <br /> <p> <b>2. Patient Information</b> </p> <p>Patient identification: (Remarks) </p> <br /> <p> <b>3. Individual Medication Counseling (Medication Counseling Order)</b> </p> <p>Virtual Session: (Remarks)</p> <p>Appointment Date: (Remarks)</p> <p>Appointment Type: (Remarks)</p> <p>Counselling Type: (Remarks) </p> <p>HMR Type: (Remarks) </p> <p>Counselling Topics: (Remarks) </p> <p>Counselling Sub-topic: (Remarks) </p> <br /> <p> <b>4. Medication Counseling Reporting</b> </p> <p>Understanding: (Remarks)</p> <p>Follow up required: (Remarks) </p></div>"
            }
        }
    ]
}

API

Operation	Address	Request Method	Example
Create Record	[base]/Composition/@FacilityCompositionIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MC-123
Update Record	[base]/Composition/@FacilityCompositionIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MC-123
Read Record	[base]/Composition/@FacilityCompositionIdentifier	GET	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MC-123

Mapping

HIE Item	Element Description	Cardinality	ValueSet/Remark	FHIR Element	FHIR Elemet DataType
Profile	Profiles this resource claims to conform to	1..1	http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core	Composition.meta.profile	Canonical
Composition Details
Category	High-level kind of a clinical document at a macro level.	1..1	ValueSetCompositionCategory (MY Core)	Composition.category.coding.code=LP173418-7	CodeableConcept
Type	Type of a composition.	1..1	ValueSetCompositionType (MY Core)	Composition.type.coding.code=34821-9	CodeableConcept
Event	The clinical service(s) being documented	1..1	ValueSetCompositionEvent (MY Core)	Composition.event.coding.code=0002-0002	CodeableConcept
Status	The workflow/clinical status of the composition.	1..1	CompositionStatus	Composition.status	CodeableConcept
Subject	Who and/or what the composition is about	1..1	Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	Composition.subject.reference	Reference
Encounter	The clinical encounter or type of care this documentation is associated with.	0..1	Reference encounter record by "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	Composition.encounter.reference	Reference
Recorder Date	Composition editing time	1..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Composition.date	DateTime
Event Date	The period covered by the documentation	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Composition.event.period.start	DateTime
Recorder	Who and/or what authored the composition	0..1		Composition.author.display	String
Facility	Organization which maintains the composition	0..1	Reference facility related by "Organization/@OrganizationPikId"	Composition.custodian.reference	Reference
Entry
Section	The root of the sections that make up the composition.	1..1	Hardcode as 55752-0	Composition.section.code.coding.code	CodeableConcept
Entry	Text summary of the section, for human interpretation	1..1	Refer JSON for MTAC content	Composition.section.text.div where Composition.section.code.coding.code=55752-0	HTML entry field

ADR report

Scenario: PhIS will send ADR report to HIE

Related Profile: Composition (MY Core)

Example JSON

{
    "resourceType": "Composition",
    "id": "HTJ-PHIS-ADR-123",
    "meta": {
        "source": "http://phis.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core"
        ]
    },
    "identifier": {
        "system": "http://fhir.hie.moh.gov.my/sid/composition-id",
        "value": "HTJ-PHIS-ADR-123"
    },
    "status": "final",
    "type": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-type-my-core",
                "code": "34821-9",
                "display": "Pharmacology Note"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core",
                    "code": "LP173418-7",
                    "display": "Note"
                }
            ]
        }
    ],
    "confidentiality": "N",
    "subject": {
        "reference": "Patient/Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|PHIS-123"
    },
    "encounter": {
        "reference": "Encounter/Encounter?identifier=http://fhir.hie.moh.gov.my/sid/encounter-id|PHIS-ENC-2212000101"
    },
    "date": "2022-09-29T12:13:00+08:00",
    "author":  [
        {
            "display": "Recorder Practitioner Name"
        }
    ],
    "title": "Note",
    "custodian": {
        "reference": "Organization/11-05060009",
        "display": "HOSPITAL TUANKU JA'AFAR"
    },
    "event":  [
        {
            "code":  [
                {
                    "coding":  [
                        {
                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core",
                            "code": "0002-0003",
                            "display": "ADR (Adverse Drug Event)"
                        }
                    ]
                }
            ],
            "period": {
                "start": "2022-09-29T12:13:00+08:00"
            }
        }
    ],
    "section":  [
        {
            "title": "Clinical Information",
            "code": {
                "coding":  [
                    {
                        "system": "http://loinc.org",
                        "code": "55752-0",
                        "display": "Clinical Information"
                    }
                ]
            },
            "text": {
                "status": "generated",
                "div": " <div xmlns=\"http://www.w3.org/1999/xhtml\"> <p> <b>1. Facility Information</b> </p> <p>Facility name &amp; ID: (Remarks) </p><br/> <p> <b>2. Patient Information</b> </p> <p>Patient identification: (Remarks) </p><br/> <p> <b>3. Adverse Reaction Description</b> </p> <p>a) Adverse Reaction Description: (Remarks)</p> <p>b) Time to Onset of Reaction (1): (Remarks)</p> <p>b) Time to Onset of Reaction (2): (Remarks)</p> <p>c) Reaction subsided after action taken with suspected drug: (Remarks) </p> <p>d) Reaction reappeared after reintroducing suspected drug: (Remarks) </p> <p>e) Outcome (Remarks) </p><br/> <p> <b>4. Suspected Drug</b> </p> <p>MDC: (Remarks)</p> <p>Product/Generic Name: (Remarks)</p> <p>Drug Type: (Remarks)</p> <p>Dose: (Remarks)</p> <p>Route: (Remarks)</p> <p>Manufacturer: (Remarks)</p> <p>Product Reg No.: (Remarks)</p> <p>Brand: (Remarks)</p> <p>Therapy Start Date: (Remarks)</p> <p>Therapy End Date: (Remarks)</p> <p>Therapy End Date Remark: (Remarks)</p> <p>Indication: (Remarks)</p></div>"
            }
        }
    ]
}

API

Operation	Address	Request Method	Example
Create Record	[base]/Encounter/@FacilityRnIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-ADR-123
Update Record	[base]/Encounter/@FacilityRnIdentifier	PUT	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-ADR-123
Read Record	[base]/Encounter/@FacilityRnIdentifier	GET	https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-ADR-123

Mapping

HIE Item	Element Description	Cardinality	ValueSet/Remark	FHIR Element	FHIR Elemet DataType
Profile	Profiles this resource claims to conform to	1..1	http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core	Composition.meta.profile	Canonical
Composition Details
Category	High-level kind of a clinical document at a macro level.	1..1	ValueSetCompositionCategory (MY Core)	Composition.category.coding.code=LP173418-7	CodeableConcept
Type	Type of a composition.	1..1	ValueSetCompositionType (MY Core)	Composition.type.coding.code=34821-9	CodeableConcept
Event	The clinical service(s) being documented	1..1	ValueSetCompositionEvent (MY Core)	Composition.event.code.coding.code=0002-0003	CodeableConcept
Status	The workflow/clinical status of the composition.	1..1	CompositionStatus	Composition.event.code.coding.code	CodeableConcept
Subject	Who and/or what the composition is about	1..1	Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	Composition.subject.reference	Reference
Encounter	The clinical encounter or type of care this documentation is associated with.	0..1	Reference encounter record by "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn\|@phisMrnNo"	Composition.encounter.reference	Reference
Recorder Date	Composition editing time	1..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Composition.date	DateTime
Event Date	The period covered by the documentation	0..1	FHIR Format YYYY-MM-DDThh:mm:ss+08:00	Composition.event.period.start	DateTime
Recorder	Who and/or what authored the composition	0..1		Composition.author.display	String
Facility	Organization which maintains the composition	0..1	Reference facility related by "Organization/@OrganizationPikId"	Composition.custodian.reference	Reference
Entry
Section	The root of the sections that make up the composition.	1..1	Hardcode as 55752-0	Composition.section.code.coding.code	CodeableConcept
Entry	"Text summary of the section, for human interpretation"	1..1	Refer JSON for MTAC content	Composition.section.text.div where Composition.section.code.coding.code=55752-0	HTML entry field

Master Drug List

Scenario: HIE will retrieve drug master list from PhIS IWP API

Related Profile: MedicationKnowledge (MY Core)

Example JSON

{
    "resourceType": "MedicationKnowledge",
    "id": "N02BE01000T1001XX",
    "meta": {
        "source": "http://provider.hie.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/MedicationKnowledge-my-core"
        ]
    },
    "extension":  [
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core",
            "extension":  [
                {
                    "url": "recorder",
                    "valueReference": {
                        "display": "Recorder Practitioner name"
                    }
                },
                {
                    "url": "recordedDate",
                    "valueDateTime": "2022-08-15T14:48:27+08:00"
                },
                {
                    "url": "lastUpdater",
                    "valueReference": {
                        "display": "Last updater Practitioner name"
                    }
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "N02BE01000T1001XX",
                "display": "Paracetamol 500 mg Tablet"
            }
        ],
        "text": "Paracetamol 500mg Tab"
    },
    "status": "active",
    "doseForm": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-dose-form-my-core",
                "code": "270",
                "display": "Oral Tablet"
            }
        ]
    },
    "synonym":  [
        "N/A"
    ],
    "productType":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-type-my-core",
                    "code": "PN",
                    "display": "PN"
                }
            ]
        }
    ],
    "ingredient":  [
        {
            "itemCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/active-ingredient-my-core",
                        "code": "410",
                        "display": "Amino acid+ dextrose+ lipid+ electrolytes"
                    }
                ],
                "text": "Amino acid+ dextrose+ lipid+ electrolytes"
            },
            "strength": {
                "numerator": {
                    "value": 500,
                    "unit": "mg",
                    "system": "http://unitsofmeasure.org",
                    "code": "mg"
                },
                "denominator": {
                    "value": 1,
                    "unit": "tablet",
                    "system": "http://unitsofmeasure.org",
                    "code": "tablet"
                }
            }
        }
    ],
    "administrationGuidelines":  [
        {
            "dosage":  [
                {
                    "type": {
                        "coding":  [
                            {
                                "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-sub-group-my-core",
                                "code": "70",
                                "display": "Parenteral Nutrition"
                            }
                        ]
                    },
                    "dosage":  [
                        {
                            "additionalInstruction":  [
                                {
                                    "coding":  [
                                        {
                                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-special-instruction-my-core",
                                            "code": "10",
                                            "display": "Administer 15-30 minutes before _____"
                                        }
                                    ],
                                    "text": "Administer 15-30 minutes before _____"
                                },
                                {
                                    "coding":  [
                                        {
                                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-cautionary-my-core",
                                            "code": "60",
                                            "display": "Avoid contact with eyes"
                                        }
                                    ],
                                    "text": "Avoid contact with eyes"
                                }
                            ],
                            "patientInstruction": "Apply as directed",
                            "timing": {
                                "code": {
                                    "coding":  [
                                        {
                                            "system": "http://terminology.hl7.org/CodeSystem/v3-GTSAbbreviation",
                                            "code": "BID",
                                            "display": "BID"
                                        }
                                    ]
                                }
                            },
                            "route": {
                                "coding":  [
                                    {
                                        "system": "http://snomed.info/sct",
                                        "code": "26643006",
                                        "display": "Oral route"
                                    }
                                ]
                            },
                            "doseAndRate":  [
                                {
                                    "doseQuantity": {
                                        "value": 500,
                                        "unit": "mg",
                                        "system": "http://unitsofmeasure.org",
                                        "code": "mg"
                                    }
                                }
                            ]
                        }
                    ]
                }
            ]
        }
    ],
    "medicineClassification":  [
        {
            "extension":  [
                {
                    "url": "http://fhir.hie.moh.gov.my/StructureDefinition/formulary-boolean-my-core",
                    "valueBoolean": true
                }
            ],
            "type": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-sub-group-my-core",
                        "code": "70",
                        "display": "Parenteral Nutrition"
                    }
                ]
            },
            "classification":  [
                {
                    "coding":  [
                        {
                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-category-my-core",
                            "code": "B",
                            "display": "B"
                        }
                    ]
                }
            ]
        }
    ],
    "regulatory":  [
        {
            "regulatoryAuthority": {
                "display": "placeholder"
            },
            "schedule":  [
                {
                    "schedule": {
                        "coding":  [
                            {
                                "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-schedule-my-core",
                                "code": "SP",
                                "display": "Schedule Poison"
                            }
                        ]
                    }
                }
            ]
        }
    ]
}

Facility Drug List

Scenario: HIE will retrieve drug master list from PhIS IWP API

Related Profile: Medication (MY Core)

Example JSON

{
    "resourceType": "Medication",
    "id": "example-medication",
    "meta": {
        "versionId": "10",
        "lastUpdated": "2022-08-22T08:29:46.670+08:00",
        "source": "http://provider.hie.moh.gov.my#luMHDWniHDEi418A",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Medication-my-core"
        ]
    },
    "extension":  [
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core",
            "extension":  [
                {
                    "url": "recorder",
                    "valueReference": {
                        "reference": "PractitionerRole/8c99c924-ba17-47aa-8bf1-b88cf0e68b61/_history/1",
                        "display": "HASAN"
                    }
                },
                {
                    "url": "recordedDate",
                    "valueDateTime": "2022-08-15T14:48:27+08:00"
                },
                {
                    "url": "lastUpdater",
                    "valueReference": {
                        "reference": "HASAN",
                        "display": "PractitionerRole/8c99c924-ba17-47aa-8bf1-b88cf0e68b61/_history/1"
                    }
                }
            ]
        },
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/service-provider-my-core",
            "valueReference": {
                "reference": "Organization/11-05060009"
            }
        },
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/medication-knowledge-my-core",
            "valueReference": {
                "reference": "MedicationKnowledge/N02BE01000T1001XX"
            }
        }
    ],
    "code": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-my-core",
                "code": "N02BE01000T1001XX",
                "display": "Paracetamol 500 mg Tablet"
            }
        ],
        "text": "Paracetamol 500mg Tab"
    },
    "status": "active"
}