Clinical Categorization Module

Context

This is the administration module for clinical categorization. It captures concepts the entire admission or case, individual services, surveys, and discharge events.

FHIR Focus Resource Types

Name Aliases Description
Structure Definition: EpisodeOfCare Profile Admission, Case, Program, Problem, Episode An association between a patient and an organization / healthcare provider(s) during which time encounters may occur. The managing organization assumes a level of responsibility for the patient during this time.
Structure Definition: Encounter Profile Visit An interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.
Structure Definition: ServiceRequest Profile Referral ---
Structure Definition: Procedure Profile Service, Codes ---
Structure Definition: Simple Observation Profile Clinical Notes, Notes A practitioner’s clinical observation or assertion about a patient’s health status, which is not a response to a screening or assessment question.
Structure Definition: Condition Problems Profile Condition, Problem, Diagnosis For practitioner notes on encounter related to condition. Capture clinical concept that is documented and categorized as a problem or health concern including information about a Social Determinants of Health-related condition.
Structure Definition: Condition Encounter Diagnosis Profile Condition, Problem, Diagnosis For encoutner diagnosis resulting from a healthcare interaction
Structure Definition: Organization Profile Provider, Provider Agency, Provider Location Organization providing services
Structure Definition: Patient Profile Client ---
Structure Definition: Practitioner Profile Clinician, physician, doctor, nurse, user See Organization Services Module
Structure Definition: PractitionerRole Profile --- See Organization Services Module
Structure Definition: ChargeItem Profile --- Not currently used
Structure Definition: Observation Screening Assessment Profile Survey Contains details on type of screening or assessment and results
Structure Definition: Questionnaire Profile Survey (DACODS, CCAR) Contains questions asked on screening or assessment
Structure Definition: QuestionnaireResponse Profile Survey Response, Answers Contains answers for questions asked on screening or assessment

Conceptual Model

Structured Screening and Assessments - Survey, Questionnaire, and Questionnaire Response

Following HL7.FHIR.US.CORE\Screening and Assessments - FHIR v4.0.01 guidance. Using the following resources:

In addition, we are utilizing the US Core Screening and Assessments guidance.

Notes

EpisodeOfCare and Encounters

Per EpisodeOfCare Boundaries and Relationships:

The primary difference between the EpisodeOfCare and the Encounter is that the Encounter records the details of an activity directly relating to the patient, while the EpisodeOfCare is the container that can link a series of Encounters together for problems/issues.

For this implementation, modifications will be made to the Clinical Categorization Resources in the Administration module:

  • Admission defines a Parent (top-level) EpisodeOfCare resource that will record Admission and Discharge Dates.
  • EspisodeOfCare is loosely based on the service category, previously defined as modality.
  • Encounter resources will be child (lower-level) pointing to a related EpisodeOfCare will collect individual service codes/procedures during a case.
  • Encounter will also be created for each event or transaction including but not limited to admission, discharge, survey, notes, and more.

Examples

Example 1 - Patient receives 2 weeks of therapy an is discharged

A patient is referred into or presents relevant healthcare issue(s), e.g., signs, symptoms, and defined conditions applicable to the Substance Use Disorder (SUD) program. A Patient and EpisodeOfCare resource will be instantiated. When that patient is associated with a managing provider (organization), the EpisodeOfCare.managingOrganization and Patient.managingOrganization SHALL be assigned to that organization.

Day 1: The patient arrives at the provider location for assessment which requires a screening and urinary analysis.

  • An Encounter is created for the overall assessment and a reasonReference is assocaited with the Procedure
  • A reasonReference is assigned to the observation screening assessment
  • Encounter.length is assigned a value based on the associated Procedure
  • EITHER
    • (Preferred) A new encounter is created for the urinary Procedure, assgined via reasonReference, with a reference in partOf pointing to the parent encounter
  • OR
    • Another reasonReference is assigned to the urinary Procedure
  • This establishes the first contact with the patient and EpisodeOfCare.period.start is assigned the same value as this Encounter.period
    • If the patient was a referral and already spoke to an agent, there may have been an Encounter for that conversation and that MAY be used as the first point of contact
  • Encounter.episodeOfCare is assigned a reference to the top-level EpisodeOfCare for each encounter
  • (WIP) Encounter.account references the Account with the main payer information.

Day 8: The patient returns to the provider location receive an in-peron therapy session.

  • A new Encounter is created and has a reasonReference to a Procedure with the applicable code for the therapy session
  • Encounter.episodeOfCare is assigned a reference to the top-level EpisodeOfCare
  • A reasonReference is created linking to a simple observation with notes from the practitioner

Day 15: The patient returns to a different provider location with the same provider to receiving a therapy session and subsequently receives a discharge, which requires a discharge survey.

  • A new Encounter is created and has a reasonReference to a Procedure with the applicable code for the therapy session
  • Encounter.episodeOfCare is assigned a reference to the top-level EpisodeOfCare
  • Encounter.length is assigned a value based on the associated Procedure
  • EITHER
    • (Preferred) A new encounter is created for the discharge survey with a reasonReference assigned for discharge survey Procedure code AND a reasonReference assigned for the disarge observation screening assessment
  • OR
    • Another reasonReference is assigned for the discharge survey Procedure AND a reasonReference assigned for the disarge observation screening assessment
  • EpisodeOfCare.period.end is assigned the same values as this Encounter.period date and EpisodeOfCare.status is changed to complete