Path | Short | Definition | Comments |
---|---|---|---|
Clinical issue with action | Indicates an actual or potential clinical issue with or between one or more active or proposed clinical actions for a patient; e.g. Drug-drug interaction, Ineffective treatment frequency, Procedure-condition conflict, etc. | ||
identifier | Unique id for the detected issue | Business identifier associated with the detected issue record. | |
status | registered | preliminary | final | amended + | Indicates the status of the detected issue. | This element is labeled as a modifier because the status contains the codes cancelled and entered-in-error that mark the issue as not currently valid. |
code | Issue Category, e.g. drug-drug, duplicate therapy, etc. | Identifies the general type of issue identified. | |
severity | high | moderate | low | Indicates the degree of importance associated with the identified issue based on the potential impact on the patient. | |
patient | Associated patient | Indicates the patient whose record the detected issue is associated with. | |
identified[x] | When identified | The date or period when the detected issue was initially identified. | |
author | The provider or device that identified the issue | Individual or device responsible for the issue being raised. For example, a decision support application or a pharmacist conducting a medication review. | |
implicated | Problem resource | Indicates the resource representing the current activity or proposed activity that is potentially problematic. | There's an implicit constraint on the number of implicated resources based on DetectedIssue.type; e.g. For drug-drug, there would be more than one. For timing, there would typically only be one. |
evidence | Supporting evidence | Supporting evidence or manifestations that provide the basis for identifying the detected issue such as a GuidanceResponse or MeasureReport. | |
evidence.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
evidence.extension | Additional content defined by implementations | 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. | 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. |
evidence.modifierExtension | Extensions that cannot be ignored even if unrecognized | 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). | 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. |
evidence.code | Manifestation | A manifestation that led to the recording of this detected issue. | |
evidence.detail | Supporting information | Links to resources that constitute evidence for the detected issue such as a GuidanceResponse or MeasureReport. | |
detail | Description and context | A textual explanation of the detected issue. | Should focus on information not covered elsewhere as discrete data - no need to duplicate the narrative. |
reference | Authority for issue | The literature, knowledge-base or similar reference that describes the propensity for the detected issue identified. | |
mitigation | Step taken to address | Indicates an action that has been taken or is committed to reduce or eliminate the likelihood of the risk identified by the detected issue from manifesting. Can also reflect an observation of known mitigating factors that may reduce/eliminate the need for any action. | |
mitigation.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
mitigation.extension | Additional content defined by implementations | 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. | 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. |
mitigation.modifierExtension | Extensions that cannot be ignored even if unrecognized | 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). | 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. |
mitigation.action | What mitigation? | Describes the action that was taken or the observation that was made that reduces/eliminates the risk associated with the identified issue. | The "text" component can be used for detail or when no appropriate code exists. |
mitigation.date | Date committed | Indicates when the mitigating action was documented. | This might not be the same as when the mitigating step was actually taken. |
mitigation.author | Who is committing? | Identifies the practitioner who determined the mitigation and takes responsibility for the mitigation step occurring. |
This resource is an event resource from a FHIR workflow perspective - see Workflow, specifically Event.
This resource applies to various circumstances where there is a concern about an existing or proposed set of clinical activity. The issue could relate to single, proposed, or multiple actions. It does not apply to technical issues (e.g. lack of user permissions) but could relate to violation of patient consent limitations. Examples include:
This resource represents a specific instance of a potential issue for a particular patient. It is not intended to represent general patient-independent knowledge. This resource is also not intended to be used in defining general prohibitions on actions such as "No NSAIDs", "No solid oral dose forms" or "No MRIs - metallic tattoos". These guidelines can be captured using the AllergyIntolerance, and/or Flag resources. Similarly, this resource is not to be used to capture clinical facts that may imply contraindications such as pregnancy, breast feeding, patient preferences, past procedures, etc. These would be represented using Condition, Procedure or other resources.
This resource only applies to documenting a risk associated with a specific planned or ongoing action, or the lack of an action which should be planned - not a general propensity to risk. The latter would be handled using AllergyIntolerance for substance-specific issues or Flag for other types of issues. In addition, the resource represents patient-specific and time-bound risk manifestations, not generic knowledge statements about risks that can exist.
This resource is limited to clinical issues associated with a proposed or ongoing action. It does not cover technical issues such as lack of permission, duplicate identifiers, insufficient data, and other business rule violations. Technical issues are conveyed using the OperationOutcome resource.
It is possible to have both OperationOutcome and DetectedIssue
together, where the OperationOutcome might
indicate that a requested action was rejected due to a clinical issue and the DetectedIssue provides the details of the issue.
Detected issues are typically identified by decision support systems. However, they may also be captured directly by clinicians. The latter typically happens for one of two reasons:
Decision-support generated issues can result from calling a decision-support engine directly (e.g. via a custom OperationDefinition) or as part of an attempt to perform some other function (creating an order, submitting an insurance claim, capturing a medication list). When the issues are generated as a by-product of performing some other sort of action, they may be included in the "response" to the requested action in the same manner as an OperationOutcome. In fact, both may be present - the OperationOutcome indicating that there was a warning or error associated with the request and a DetectedIssue providing the clinical details. (The OperationOutcome could point to the DetectedIssue via an extension.)
In those circumstances where requested operations are rejected as a result of a detected issue, the workflow may support allowing the operation to be re-tried, provided that the identified issue is included as part of the submission (possibly also including a mitigation). In doing so, the sender acknowledges the issue and takes responsibility for it, thus allowing the requested operation to proceed. See Linking to Detected Issues for guidance on how a DetectedIssue instance might be included as part of another operation.
Systems that require such workflows should document expected behavior as part of their CapabilityStatement declarations.
DetectedIssue follows the pattern of linking from the resource created "second". As DetectedIssue originates in response to one or more other existing records, it points to those records rather than being pointed to from them.
In some cases, a detected issue might be associated with a single record. When this occurs, it may be stored as a contained resource within the implicated resource provided that there is no expected need to search for the detected issue directly. However, with detected issues that implicate multiple records, containment is more problematic. In some workflows, a detected issue might be deemed to be "owned" by the record whose creation triggers the contraindication being created - i.e. the "second" or "last" record. However, where multiple actions are proposed as part of a single submission, there can be no single owner and containment will not be feasible.
If there is a strong need to point from an implicated resource to DetectedIssue and containment is not appropriate, an extension can be used.
DetectedIssue is a resource that is frequently associated with workflow challenges where frequent alerts that are not clinically relevant result in clinicians tuning out (or turning off) the content and thus missing relevant alerts. Give consideration to this issue before making heavy use of this resource.
author | The provider or device that identified the issue | DetectedIssue.author |
code | Issue Category, e.g. drug-drug, duplicate therapy, etc. | DetectedIssue.code |
identified | When identified | DetectedIssue.identified |
implicated | Problem resource | DetectedIssue.implicated |