clin ical scenario

Objective: Familiarize with FHIR, the state of the art standard clinical data model

Description: This assignment requires to document a simple scenario, where a physician reads a patient’s body temperature during an outpatient encounter.
To this end, we will use the open editor ‘FRED (Links to an external site.)‘ to instantiate and validate a few FHIR resources

Rationale: Documentation stored in a medical record by means of structured data can help organize, retrieve, exchange and process the information – including for purposes such as analytics and decision support.

However, capturing structured data is a non-trivial process, and particular care is needed to ensure that the data is coherent and consistent. Most EHRs (try to) hide the complexity, with various degrees of success. This assignment is intended to expose you to some of that complexity, so you can better understand the challenges and opportunities.   

Instructions: 

• Setup your session:
  • Open the FRED web application at http://docs.smarthealthit.org/fred/ (Links to an external site.)
  • Click on the button “Open a new resource”
  • In the popup:
    • Select the “Blank Resource” tab
    • Choose the “Patient” resource
    • Click the “Create in a Bundle” checkbox
    • Click on “Create Resource”
• “Bundles” are collections of FHIR resources, which roughly correspond to structured medical record entries. The bar at the top of the screen lets you add, remove or navigate between resources in your bundle. A resource of type Patient is ready for you to edit
• Once you have selected a resource, you can add elements (fields/attributes) that depend on the type of resource. Edit the value of the attribute, then confirm with the ‘tick’ button 
• At the end of your data capture session, click on “Export JSON” and submit the file to blackboard.

Using the tool, create the following resources in your bundle: 

• Create a Patient (Links to an external site.) resource, populating at least the following fields:
  • id, name, gender, birthdate, deceased, address {5pts}  
• Create an Observation (Links to an external site.) resource, poupulating at least the following fields:
  • id, status (“final”), code (“Temperature of skin”), value/String, interpretation, bodySite {5pt}
• Create a Practitioner (Links to an external site.) resource, populating at least the following fields:
  • id, name {5pt}
• Create an Encounter (Links to an external site.) resource, populating at least the following fields:
  • id, status (“finished”), class (“ambulatory encounter”), reason, period {5pt}

You will notice that, in FHIR:

• Every resource has an identifer: it can be any sequence of characters you want, as long as it is unique for each resource
• Identifiers are used in ‘References’, to link e.g. your Observation to your Patient
• Some fields are ‘coded’
  • Sometimes FHIR defines the admissible values (e.g. Patient.gender)
  • Sometimes the code comes from a standard terminology system such as SNOMED or LOINC
    (e.g the Observation type) 

Try to handle identifiers, relationships and codes properly {5pt}