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HL7 FHIR documents

An explanation of the implementation of ZD Documents

FHIR documents

One of the core functionalities of the ZorgDomein application is to generate transactions such as referrals and healthcare requests. Using these transactions, healthcare practitioners can share logistic and medical patient information with each other. This information is exchanged using medical documents. The FHIR Edition of our interface expresses these documents as FHIR documents. According to the formal definition of FHIR Documents , FHIR resources can be used to build documents that represent a composition: a set of coherent information that is a statement of healthcare information, including clinical observations and services. A document is an immutable set of resources with a fixed presentation that is authored and/or attested by humans, organizations and devices.

Document structure

All FHIR documents have the same structure. The document itself is represented by a FHIR Bundle resource, wich is (as the name suggests) a bundle of several different resources that together make up the content of the document.  The first resource in the Bundle is always  a Composition resource, followed by a series of other resources, referenced from the Composition resource. The Bundle gathers all the content of the document into a single XML or JSON document. The Composition resource is the foundation of the clinical document. It:

  • Provides identity and its purpose, sets the context of the document
  • Carries key information such as the subject and author, and who attests to the document
  • Divides the document up into a series of sections, each with their own narrative

According to the ZD Document profile, the key attributes of the Composition resource in the ZorgDomein FHIR Document are: 

  • extension.zd-sender - reference to a PractitionerRole resource which represents the responsible sender of the document. The PractitionerRole resource refers to:
    • PractitionerRole.practitioner - Practitioner resource that represents the actual responsible sender.
    • PractitionerRole.organization - Organization resource that represents the organization that the responsible sender belongs to.
    • PractitionerRole.location - Location resource that represents the location of the organization that the responsible sender belongs to.
  • extension.zd-actingpractitioner -  reference to a Practitioner resource which represents the acting sender of the document. Please note that there is a difference between the acting sender and the responsible sender. ZorgDomein supports the scenario in which an acting practitioner acts on behalf of a responsible practitioner. 
  • extension.zd-recipient - reference to a PractitionerRole resource which represents the intended recipient of the document. The PractitionerRole resource refers to:
    • PractitionerRole.practitioner - Practitioner resource that represents the intended recipient in case the document is to be delivered at a specific person.
    • PractitionerRole.organization - Organization resource that represents the organization that the document is aimed at.
    • PractitionerRole.location - Location resource that represents the location of the organization that the document is aimed at.
  • extension.zd-destination - reference to a PractitionerRole resource which represents to which the document must be routed. The PractitionerRole resource refers to:
    • PractitionerRole.practitioner - Practitioner resource that represents the destination in case the document must be routed to a specific person.
    • PractitionerRole.organization - Organization resource that represents the organization that the document must be routed to.
    • PractitionerRole.location - Location resource that represents the location of the organization that the document must be routed to.
  • zd-pdfDocument - reference to a DocumentReference resource that contains a Base64 encoded representation of the document in pdf format.
  • identifier - ZD number of the transaction to which the document belongs.
  • type - document type.
  • subject - reference to a Patient resource which represents the patient that is the document's subject.
  • date - creation date of the document.
  • author - Practitioner resource that represents the actual responsible sender.

Please note:

  • The difference between the zd-recipient and zd-destination extensions may not be evident, but is crucial. For documents that are delivered at the intended recipient these values are identical. However, if the sender of the document has logged in to ZorgDomein through a FHIR interface, ZorgDomein also sends a copy of the submitted document back to the sender. For these copies, the values of these two extensions are different: 
    • For copy documents, zd-recipient points to the intended recipient of the document
    • For copy documents, zd-destination points to the sender of the document
    This means that the zd-destination  extension should be used for delivering the document at the right organization or user in the XIS.
    Furthermore, by comparing the values of zd-recipient and zd-destination, the XIS can determine wether the document is a copy of a sent message (which can be archived as outgoing message) or an incoming new message that should be notified by the recipient. If the values of these two extension are identical, the document is a new message, if the values are different it is a copy document. 
  • The author attribute refers to the same Practitioner resource as referred to by the zd-sender extension. Because the author attribute only allows for references to Practitioner resources, we have chosen to introduce the zd-sender extention which is a reference to a PractitionerRole resource which allows us to refer to a Practitioner, Organization and Location resource. 

Any resource referenced directly in the Composition will be included in the Bundle. See the diagram below for a schematic representation of the structure of a FHIR Document and how the different resource refer to each onther (each block within the Bundle represents a resource in the Bundle). 

Bundle (type = "Document")
Composition
extension.zd-actingpractitioner
extension.zd-sender
extension.zd-recipient
extension.zd-destination
extension.zd-pdfDocument
identifier
class
subject
date
author
...
section
text
entry
section
text
entry
...
PractitionerRole (sender)
practitioner
organization
location
PractitionerRole (receiver)
organization
location

Document types

For the different transactions that ZorgDomein supports, ZorgDomein will send different document types. The type of document is captured in the composition.type element of the FHIR document.  This element can contain the following values: 

  • Aanvraagformulier: request form for specific research, procedure or service, e.g. diagnostic research, operation request ("uitvoeringsverzoek"), delivery request ("leveringsverzoek") or placement request ("plaatsingsverzoek")
  • Afnameformulier: laboratory collection form (only relevant for laboratory order management systems)
  • Afspraakbericht: appointment request message
  • Annuleringsbericht: cancellation message
  • Nazending: document containing supplemental attachments for the referral letter
  • Rapportage: copy of a report that was sent by the care provider
  • Teleconsultatie aanvraagformulier: request for teleconsultation
  • Verwijsbrief: referral letter or document containing attachments for the referral letter
  • Vragenlijst: questionnaire accomplishing a referral or request
  • Patiëntoverleg: export of a conversation in ZorgDomein Patiëntoverleg (the ZorgDomein messenger app)

Not all document type will be relevant for all systems, or some systems will not be able to process specific document types. Please contact us at the start of the development of the interface to discuss which document types should be implemented. If at any point you receive a document type that is unknown to you or cannot be processed, you must return a HTTP 422 response. 

Sending Documents

Assembled documents will be sent by ZorgDomein to the Bundle-endpoint of the receiving XIS. This is done by the HTTP POST-method, so a Document with id 123-456 will be POST to /Bundle/ with the XML- or JSON-representation of the document in the body of the HTTP-call.

  • Deze informatie is alleen beschikbaar in het Engels.
  • The information on this page applies to ZorgDomein Integrator FHIR Edition.