The individual's statement about a refused correction, attached to the disputed record
Definition
A message about a patient. Either WELL-internal staff chat, or eReferral correspondence
exchanged with an external partner. category distinguishes them and readers should scope
on it -- the two populations have different authorities over their content.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
Comments
The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
When the resource last changed - e.g. when the version changed.
Comments
This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
Identifies EMR instance & pipeline version the resource came from
Definition
A URI that identifies the EMR pipeline and version from which this resource originated. This tells you which EMR instance (recommend using the instance identifier), and the version of the pipeline code/transformations.
Comments
In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.
This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
Comments
The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
Comments
The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
A set of rules under which this content was created
Definition
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Comments
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Cardinality
0..1
Type
uri
Modifier
yes — This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The base language in which the resource is written.
Comments
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
A human-readable narrative summary of the NexusEmrCoreCommunication resource for human interpretation.
Comments
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Comments
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality
0..*
Type
Extension
Modifier
yes — Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Unique identifiers for the communication.
A business identifier is recommended but not required (identifier is 0..*). For eReferral traffic this is where the partner's own message identifier belongs -- it is the only governed way to correlate a reply with what it replies to across the boundary.
⚠ HERITAGE EMR SITUATION -- UNRESOLVED. Heritage EMRs have internal messaging and inbox features, but they are NOT modelled as FHIR Communication: they are local message tables with their own threading, read/unread state, and per-user routing that has no FHIR equivalent. Nothing currently maps them into this resource. Two consequences: (1) a heritage-sourced message has no identifier this IG can name, so any ingest would have to mint one, and (2) migrating that history at all is an open decision -- the alternative is to leave heritage messages in the source system and have this resource cover only natively-authored traffic. Until that is decided, treat every Communication here as either WELL-internal-native or external eReferral, never heritage-migrated.
If no recognized system exists, implementers MAY invent a URI for the system.
A source system's own identifier SHOULD be carried alongside this one, flagged use = secondary. See Carrying the raw code.
Requirements
Allows identification of the communication as it is known by various participating systems and in a way that remains consistent across servers.
Comments
This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
Requirements
Allows users to make use of identifiers when the identifier system is not known.
Comments
This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.
Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
Requirements
There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
Comments
If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
The URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this Communication.
Comments
This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
The clinical Task that carried the correction request through to its refusal -- the one whose
businessStatus reached denied. Where the producer declares it, that Task is a
correction task; this element does not require the
declaration, because nothing in this estate writes meta.profile onto a Task today.
This is the audit trail: it names who decided, when, and on what stated reason. It is NOT how a
release path finds this statement. Disclosure assembly reads about, because the obligation
attaches to the clinical record rather than to the workflow, and the workflow closes.
HL7's Patient Request for Corrections guide carries the Task association in an about slice and
uses partOf for message threading. This guide reverses that, so that about holds only the
disputed records and a release path can read it without filtering. A consumer converting between
the two must move the reference rather than copy it.
The custodian's notice of refusal, where one was sent
Definition
The Communication in which the custodian told the individual their correction request was refused. Optional, and its absence says nothing about whether the refusal was communicated -- it may have been given verbally or on paper.
Comments
⚠ FIRST PASS. The chat panel currently threads by neither inResponseTo nor partOf -- conversation order is reconstructed from timestamps, which is why concurrent messages can interleave wrongly. Declaring the element here is the first step; deciding whether threads are inResponseTo chains or a partOf grouping is open.
The lifecycle of the MESSAGE, not of the obligation. completed means the statement was received
and recorded. It does not mean the matter is closed, and it has no bearing on whether the
statement must still be included in a disclosure -- it must.
entered-in-error is the only route to withdrawing a statement, and it must be used only where
the statement was recorded in error. An individual who wishes to change their statement supplies a
new one; the original remains in version history, because a custodian deleting an individual's
account of a dispute is the shape of the problem the right exists to prevent.
Comments
Internal chat writes completed on send. For eReferral traffic the partner's lifecycle applies and status is pass-through -- do not infer local workflow state from it.
Cardinality
1..1
Type
code
Must Support
yes
Modifier
yes — This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Captures the reason for the current state of the Communication.
Comments
This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here.
Carries the HL7 correction vocabulary's disagreement code, so that a consumer scanning a patient's
Communications can find every statement of disagreement without knowing this guide's profile URL.
The parent profile leaves category unbound and text-tolerant. This profile requires a coded one,
because a statement nobody can find is a statement nobody will include.
Comments
⚠ FIRST PASS -- no value set is bound yet, deliberately. Binding one requires deciding the pass-through boundary first (a partner-supplied category must remain conformant), and that decision is not made. Until then this is text-or-code and readers MUST tolerate text-only. A local NexusEmrCommunicationCategoryVS is the intended follow-up.
Carries the HL7 correction vocabulary's disagreement code, so that a consumer scanning a patient's
Communications can find every statement of disagreement without knowing this guide's profile URL.
The parent profile leaves category unbound and text-tolerant. This profile requires a coded one,
because a statement nobody can find is a statement nobody will include.
Comments
The code comes from HL7's Patient Request for Corrections COMMUNICATION type system, not its TASK
type system. Both publish a code spelled medRecCxDenialDisagree, at different canonical URLs. A
coding carrying the right code under the wrong system is not equivalent and a consumer matching on
code alone will not notice the difference.
The system is not resolvable in this build -- that package is deliberately not a dependency -- so
terminology-aware validators will report that this code cannot be verified. That is expected.
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
A reference to a code defined by a terminology system.
Requirements
Allows for alternative encodings within a code system, and translations to other code systems.
Comments
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
The identification of the code system that defines the meaning of the symbol in the code.
Requirements
Need to be unambiguous about the source of the definition of the symbol.
Comments
The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Comments
Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
Requirements
This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
Comments
Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Requirements
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Comments
Very often the text is the same as a displayName of one of the codings.
The records whose disclosure must carry this statement. At least one is required: a statement with
no target cannot be attached to anything, and a release path has nothing to test.
Version-pinned or not -- carry BOTH, and the reason matters. A reference including a _history
version pins the exact content the individual disputed, which is what an auditor needs. But a
version-pinned reference alone will NOT cause a current-state export to include the statement,
because a consumer assembling today's chart never looks at that version. Add an unversioned
reference to the same logical record so the statement travels with whatever that record now says.
A statement associated only with a superseded version stops being disclosed the moment the record
is edited for any unrelated reason, and nothing reports that it has.
Comments
Deliberately NOT sliced. Separating the disputed record from the workflow Task by reference target
type needs a discriminator that resolves the reference, which this guide's evaluable-slicing
convention avoids -- an unevaluable slice renders on the published page and then checks nothing.
The correction Task is carried on partOf instead, so the two associations sit on different
elements and no discriminator is needed.
The Encounter during which this Communication was created or to which the creation of this record is tightly associated.
Comments
This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.
The entity (e.g. person, organization, clinical information system, care team or device) which was the target of the communication. If receipts need to be tracked by an individual, a separate resource instance will need to be created for each recipient. Multiple recipient communications are intended where either receipts are not tracked (e.g. a mass mail-out) or a receipt is captured in aggregate (all emails confirmed received by a particular time).
The individual, or their substitute decision-maker
Definition
Who is making the statement. Narrowed from the parent profile to exactly these two, because the
right of reply belongs to the individual and to nobody else.
A substitute decision-maker is a RelatedPerson. Recording an SDM's statement as though the
patient made it loses the fact that authority was delegated, which is precisely what gets checked
when the statement is later challenged.
Comments
Practitioner is the primary provider identity in this IG. Organization covers a partner-system sender on inbound eReferral traffic; Device covers system-generated messages. RelatedPerson covers a SUBSTITUTE DECISION-MAKER acting for the patient -- a distinct fact from the patient acting themselves, and one that must not be flattened onto Patient: where a right over the record is exercised by proxy, the record has to show that authority was delegated, because that is what is checked when the exercise is challenged.
The statement itself, in the individual's own words
Definition
The statement. Required, and at least one payload must carry the text.
contentString for a statement given in writing or transcribed verbatim; contentAttachment or a
contentReference to a DocumentReference for a signed letter the individual supplied.
Not summarised, not paraphrased, not edited. The content is disclosed as the individual wrote
it. A clinic that condenses a statement into a chart note has substituted its own account for the
one PHIPA entitles the individual to have carried.
Comments
Internal chat writes contentString. eReferral traffic may carry contentAttachment or contentReference -- a reader that assumes contentString will silently render an empty message. Handle all three.
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extensions that cannot be ignored even if unrecognized
Definition
May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality
0..*
Type
Extension
Modifier
yes — Modifier extensions are expected to modify the meaning or interpretation of the element that contains them