FHIR Release 3 (STU) CI-Build

This page is part of the FHIR Specification (v3.0.2: STU 3). The current version which supercedes this version is 5.0.0 . For a full list Continuous Integration Build of available versions, see FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions icon . Page versions: R5 R4B R4 R3 R2

9.10 9.9 Resource DetectedIssue - Content

Responsible Owner: Clinical Decision Support icon Work Group   Normative Maturity Level : 1   Trial Use Security Category : Patient Compartments : Device , Group , Patient , Practitioner

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, gaps in care, etc.

9.10.1 9.9.1 Scope and Usage

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:

  • Drug-drug interactions
  • Inappropriate therapy (wrong dose, frequency, body site)
  • Duplicate therapy
  • Gaps in care

This resource represents a specific instance of a potential issue for a particular patient. It is not intended to represent general patient-independent knowledge. knowledge, the ClinicalUseDefinition resource is defined for that purpose. This resource is also not intended to be used in defining general prohibitions on actions such as "No NSAIDs", "No "No NSAIDs", "No solid oral dose forms" forms" or "No "No MRIs - metalic tatoos". metallic tattoos". These guidelines can be captured using the AllergyIntolerance , AdverseEvent and/or Flag resources. Similarly 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. The DetectedIssue resource is not intended to be used to capture alerts from devices such as heart monitors.

9.10.2 9.9.2 Boundaries and Relationships

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 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.

When author is a Device in a DetectedIssue, this typically represents the software service that supplied the detected issue as part of a clinical decision support request and response, as opposed to an alert from a monitoring device. The DeviceAlert resource should be used for that use case.

9.10.3 9.9.3 Background and Context

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:

  1. A clinician wishes to communicate an issue to another clinician whose responsibility would be to resolve it (e.g. a pharmacist identifying an issue with a prescription prior to putting it on hold)
  2. A clinician wishes to pre-emptively identify that an issue is known and is being managed (to avoid red flags being raised as part of downstream workflow); e.g. Submitting a new order and including a link to a "duplicate therapy" "duplicate therapy" issue with mitigation indicating that the therapy is not considered to be duplicate.

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" "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.

This resource is referenced by

9.9.4 References to this Resource

9.10.4 9.9.5 Resource Content

Structure

0..1 Unique id registered | Issue Category,
Name Flags Card. Type Description & Constraints      Filter: Filters doco
. . DetectedIssue N DomainResource Clinical issue with action

Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ 0..* Identifier Business identifier for the detected issue

. . . status ?! Σ 1..1 code preliminary | final | amended + entered-in-error | unknown | mitigated | processing-error
ObservationStatus Binding: Detected Issue Status ( Required )
. . . category Σ 0..* CodeableConcept 0..1 High level categorization of detected issue
Binding: Detected Issue Category ( Preferred )

. . . severity Σ 0..1 code CodeableConcept high | moderate | low
DetectedIssueSeverity Binding: Detected Issue Severity ( Required Preferred )
. . . patient subject Σ 0..1 Reference ( Patient | Group | Device | Location | Organization | Procedure | Practitioner | Medication | Substance | BiologicallyDerivedProduct | NutritionProduct ) Associated patient subject
. . date . encounter Σ 0..1 Reference ( Encounter ) Encounter the detected issue is part of
... identified[x] Σ 0..1 When detected issue occurred/is occurring
.... identifiedDateTime 0..1 dateTime When identified
. . . . identifiedPeriod Period
.... identifiedTiming Timing
. . . author Σ 0..1 Reference ( Patient | RelatedPerson | Practitioner | PractitionerRole | Device ) The provider or device that identified the issue
. . . implicated Σ 0..* Reference ( Any ) Problem resource

. . . evidence 0..* BackboneElement Supporting evidence

. . . . code 0..* CodeableConcept Manifestation
Binding: Manifestation and Symptom Codes ( Example )

.... detail 0..* 0..1 Reference ( Any ) Supporting information

string
. . . detail 0..1 markdown Description and context
. . . reference 0..1 uri Authority for issue
. . mitigation . qualityOfEvidence 0..1 CodeableConcept The quality of the evidence supporting the detected issue
Binding: QualityOfEvidenceRating icon ( Example )
... expectedOnsetType 0..1 CodeableConcept Time frame of clinical effect
Binding: Detected Issue Expected Onset Type ( Example )
... medicationClass 0..* CodeableConcept BackboneElement What medication class
Binding: Detected Issue Example Medication Class ( Example )

. . . managementCode 0..1 CodeableConcept Importance of taking action on the issue
Binding: Detected Issue Management Code ( Example )
... mitigation 0..* BackboneElement Step taken to address

. . . . action 1..1 CodeableConcept What mitigation?
Binding: Detected Issue Mitigation Action ( Preferred )
. . . . date 0..1 dateTime Date committed
. . . . author 0..1 Reference ( Practitioner | PractitionerRole ) Who is committing?
. . . . note 0..* Annotation Additional notes about the mitigation


doco Documentation for this format icon

See the Extensions for this resource

UML Diagram ( Legend )

DetectedIssue ( DomainResource ) Business identifier associated with the identifiers assigned to this detected issue record by the performer and/or other systems. These identifiers remain constant as the resource is updated and propagates from server to server identifier : Identifier [0..1] [0..*] Indicates the status The current state of the detected issue (this element modifies the meaning of other elements) status : code [1..1] « Indicates the status of the identified issue null (Strength=Required) ObservationStatus DetectedIssueStatus ! » Identifies Partitions the general type of detected issue identified into one or more categories that can be used to filter searching, to govern access control and/or to guide system behavior category : CodeableConcept [0..1] [0..*] « Codes identifying null (Strength=Preferred) DetectedIssueCategory ? » A code that identifies the general specific type of issue detected issue; e.g. Drug-drug interaction, Timing issue, Duplicate therapy, etc. code : CodeableConcept [0..1] « null (Strength=Preferred) Detected Issue Category DetectedIssueCode ? » Indicates the degree of importance associated with the identified issue based on the potential impact on the patient severity : code CodeableConcept [0..1] « Indicates the potential degree of impact of the identified issue on the patient. (Strength=Required) null (Strength=Preferred) DetectedIssueSeverity ! ? » Indicates the patient subject whose record the detected issue is associated with patient subject : Reference [0..1] « Patient | Group | Device | Location | Organization | Procedure | Practitioner | Medication | Substance | BiologicallyDerivedProduct | NutritionProduct » The date Encounter during which this detected issue was created or date-time to which the creation of this record is tightly associated encounter : Reference [0..1] « Encounter » The date, period or timing when the detected issue was initially identified did occur or is occurring date identified[x] : dateTime DataType [0..1] « dateTime | Period | Timing » Individual or device responsible for the issue being raised. For example, a decision support application or a pharmacist conducting a medication review author : Reference [0..1] « Patient | RelatedPerson | Practitioner | PractitionerRole | Device » Indicates the resource representing the current activity or proposed activity that is potentially problematic implicated : Reference [0..*] « Any » A textual explanation of the detected issue detail : string markdown [0..1] The literature, knowledge-base or similar reference that describes the propensity for the detected issue identified reference : uri [0..1] The quality of the evidence supporting identification of the detected issue. The code system used specifies the quality scale used to grade this evidence source while the code specifies the actual quality score (represented as a coded value) associated with the evidence qualityOfEvidence : CodeableConcept [0..1] « null (Strength=Example) QualityOfEvidenceRating ?? » The time frame in which the clinical effects of the detected issue may be expected to occur. Rapid refers to an expected onset within 24 hours. Delayed refers to an expected onset in more than 24 hours expectedOnsetType : CodeableConcept [0..1] « null (Strength=Example) DetectedIssueExpectedOnsetType ?? » Represents the medication class that is responsible for the detected issue medicationClass : CodeableConcept [0..*] « null (Strength=Example) DetectedIssueExampleMedicatio... ?? » An indication of the importance or type of step that should or may be taken in order to address the detected issue. This is different than mitigation in that it is not specifically providing actions to be taken, rather general suggestions about approach managementCode : CodeableConcept [0..1] « null (Strength=Example) DetectedIssueManagementCode ?? » Evidence A manifestation that led to the recording of this detected issue code : CodeableConcept [0..*] « null (Strength=Example) ManifestationAndSymptomCodes ?? » Links to resources that constitute evidence for the detected issue such as a GuidanceResponse or MeasureReport detail : Reference [0..*] « Any » Mitigation Describes the action that was taken or the observation that was made that reduces/eliminates the risk associated with the identified issue action : CodeableConcept [1..1] « Codes describing steps taken to resolve the issue or other circumstances that mitigate the risk associated with the issue; e.g. 'added concurrent therapy', 'prior therapy documented', etc. null (Strength=Preferred) Detected Issue Mitigation Act... DetectedIssueMitigationAction ? » Indicates when the mitigating action was documented date : dateTime [0..1] Identifies the practitioner who determined the mitigation and takes responsibility for the mitigation step occurring author : Reference [0..1] « Practitioner | PractitionerRole » Clinicians may add additional notes or justifications about the mitigation action. For example, patient can have this drug because they have had it before without any issues. Multiple justifications may be provided note : Annotation [0..*] Supporting evidence or manifestations that provide the basis for identifying the detected issue such as a GuidanceResponse or MeasureReport evidence [0..*] Indicates an action that has been taken or is committed to 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 [0..*]

XML Template 

<

<DetectedIssue xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <
 <</category>
 <
 <</patient>
 <
 <</author>

 <identifier><!-- 0..* Identifier Business identifier for detected issue --></identifier>
 <status value="[code]"/><!-- 1..1 preliminary | final | entered-in-error | unknown | mitigated | processing-error -->
 <category><!-- 0..* CodeableConcept High level categorization of detected issue --></category>
 <code><!-- 0..1 CodeableConcept Specific type of detected issue, e.g. drug-drug, duplicate therapy, etc --></code>
 <severity><!-- 0..1 CodeableConcept high | moderate | low --></severity>
 <subject><!-- 0..1 Reference(BiologicallyDerivedProduct|Device|Group|Location|
   Medication|NutritionProduct|Organization|Patient|Practitioner|Procedure|
   Substance) Associated subject --></subject>

 <encounter><!-- 0..1 Reference(Encounter) Encounter the detected issue is part of --></encounter>
 <identified[x]><!-- 0..1 dateTime|Period|Timing When detected issue occurred/is occurring --></identified[x]>
 <author><!-- 0..1 Reference(Device|Patient|Practitioner|PractitionerRole|
   RelatedPerson) The provider or device that identified the issue --></author>
 <implicated><!-- 0..* Reference(Any) Problem resource --></implicated>
 <
 <
 <

 <evidence>  <!-- 0..* Supporting evidence -->
  <code><!-- 0..* CodeableConcept Manifestation --></code>
  <detail><!-- 0..* Reference(Any) Supporting information --></detail>
 </evidence>
 <detail value="[markdown]"/><!-- 0..1 Description and context -->
 <reference value="[uri]"/><!-- 0..1 Authority for issue -->
 <qualityOfEvidence><!-- 0..1 CodeableConcept The quality of the evidence supporting the detected issue icon --></qualityOfEvidence>
 <expectedOnsetType><!-- 0..1 CodeableConcept Time frame of clinical effect --></expectedOnsetType>
 <medicationClass><!-- 0..* CodeableConcept What medication class --></medicationClass>
 <managementCode><!-- 0..1 CodeableConcept Importance of taking action on the issue --></managementCode>
 <mitigation>  <!-- 0..* Step taken to address -->

  <action><!-- 1..1 CodeableConcept What mitigation? --></action>
  <
  <</author>

  <date value="[dateTime]"/><!-- 0..1 Date committed -->
  <author><!-- 0..1 Reference(Practitioner|PractitionerRole) Who is committing? --></author>
  <note><!-- 0..* Annotation Additional notes about the mitigation --></note>

 </mitigation>
</DetectedIssue>

JSON Template 

{doco
  "resourceType" : "",

  "resourceType" : "DetectedIssue",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
    "
    "
    "

  "identifier" : [{ Identifier }], // Business identifier for detected issue
  "status" : "<code>", // R!  preliminary | final | entered-in-error | unknown | mitigated | processing-error
  "category" : [{ CodeableConcept }], // High level categorization of detected issue
  "code" : { CodeableConcept }, // Specific type of detected issue, e.g. drug-drug, duplicate therapy, etc
  "severity" : { CodeableConcept }, // high | moderate | low
  "subject" : { Reference(BiologicallyDerivedProduct|Device|Group|Location|
   Medication|NutritionProduct|Organization|Patient|Practitioner|Procedure|
   Substance) }, // Associated subject

  "encounter" : { Reference(Encounter) }, // Encounter the detected issue is part of
  // identified[x]: When detected issue occurred/is occurring. One of these 3:

  "identifiedDateTime" : "<dateTime>",
  "identifiedPeriod" : { Period },
  "identifiedTiming" : { Timing },
  "author" : { Reference(Device|Patient|Practitioner|PractitionerRole|
   RelatedPerson) }, // The provider or device that identified the issue

  "implicated" : [{ Reference(Any) }], // Problem resource
  "evidence" : [{ // Supporting evidence
    "code" : [{ CodeableConcept }], // Manifestation
    "detail" : [{ Reference(Any) }] // Supporting information
  }],
  "detail" : "<markdown>", // Description and context
  "reference" : "<uri>", // Authority for issue
  "qualityOfEvidence" : { CodeableConcept }, // The quality of the evidence supporting the detected issue icon
  "expectedOnsetType" : { CodeableConcept }, // Time frame of clinical effect
  "medicationClass" : [{ CodeableConcept }], // What medication class
  "managementCode" : { CodeableConcept }, // Importance of taking action on the issue
  "mitigation" : [{ // Step taken to address
    "action" : { CodeableConcept }, // R!  What mitigation?
    "date" : "<dateTime>", // Date committed
    "author" : { Reference(Practitioner|PractitionerRole) }, // Who is committing?
    "note" : [{ Annotation }] // Additional notes about the mitigation

  }]
}

Turtle Template 

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:;

[ a fhir:DetectedIssue;

  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from 
  # from 
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
  ], ...;

  # from Resource: fhir:id, fhir:meta, fhir:implicitRules, and fhir:language
  # from DomainResource: fhir:text, fhir:contained, fhir:extension, and fhir:modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business identifier for detected issue
  fhir:status [ code ] ; # 1..1 preliminary | final | entered-in-error | unknown | mitigated | processing-error
  fhir:category  ( [ CodeableConcept ] ... ) ; # 0..* High level categorization of detected issue
  fhir:code [ CodeableConcept ] ; # 0..1 Specific type of detected issue, e.g. drug-drug, duplicate therapy, etc
  fhir:severity [ CodeableConcept ] ; # 0..1 high | moderate | low
  fhir:subject [ Reference(BiologicallyDerivedProduct|Device|Group|Location|Medication|NutritionProduct|
  Organization|Patient|Practitioner|Procedure|Substance) ] ; # 0..1 Associated subject

  fhir:encounter [ Reference(Encounter) ] ; # 0..1 Encounter the detected issue is part of
  # identified[x] : 0..1 When detected issue occurred/is occurring. One of these 3
    fhir:identified [  a fhir:DateTime ; dateTime ]
    fhir:identified [  a fhir:Period ; Period ]
    fhir:identified [  a fhir:Timing ; Timing ]
  fhir:author [ Reference(Device|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 The provider or device that identified the issue
  fhir:implicated  ( [ Reference(Any) ] ... ) ; # 0..* Problem resource
  fhir:evidence ( [ # 0..* Supporting evidence
    fhir:code  ( [ CodeableConcept ] ... ) ; # 0..* Manifestation
    fhir:detail  ( [ Reference(Any) ] ... ) ; # 0..* Supporting information
  ] ... ) ;
  fhir:detail [ markdown ] ; # 0..1 Description and context
  fhir:reference [ uri ] ; # 0..1 Authority for issue
  fhir:qualityOfEvidence [ CodeableConcept ] ; # 0..1 The quality of the evidence supporting the detected issue
  fhir:expectedOnsetType [ CodeableConcept ] ; # 0..1 Time frame of clinical effect
  fhir:medicationClass  ( [ CodeableConcept ] ... ) ; # 0..* What medication class
  fhir:managementCode [ CodeableConcept ] ; # 0..1 Importance of taking action on the issue
  fhir:mitigation ( [ # 0..* Step taken to address
    fhir:action [ CodeableConcept ] ; # 1..1 What mitigation?
    fhir:date [ dateTime ] ; # 0..1 Date committed
    fhir:author [ Reference(Practitioner|PractitionerRole) ] ; # 0..1 Who is committing?
    fhir:note  ( [ Annotation ] ... ) ; # 0..* Additional notes about the mitigation
  ] ... ) ;

]

Changes since DSTU2 from both R4 and R4B

DetectedIssue
DetectedIssue.status
  • Change value set from http://hl7.org/fhir/ValueSet/observation-status|4.0.0 to Detected Issue Status
  • Remove codes registered , amended , corrected , cancelled
  • Add code mitigated
DetectedIssue.category
  • Added Element
DetectedIssue.severity
  • Type changed from code to CodeableConcept
  • Remove Binding `http://hl7.org/fhir/ValueSet/detectedissue-severity|4.0.0` (required)
DetectedIssue.subject
  • Added Element
DetectedIssue.encounter
  • Added Element
DetectedIssue.identified[x]
  • Add Type Timing
DetectedIssue.author
  • Type Reference: Added Target Types Patient, RelatedPerson
DetectedIssue.detail
  • Type changed from string to markdown
DetectedIssue.qualityOfEvidence
  • Added Element
DetectedIssue.expectedOnsetType
  • Added Element
DetectedIssue.medicationClass
  • Added Element
DetectedIssue.managementCode
  • Added Element
DetectedIssue.mitigation.note
  • Added Element
DetectedIssue.patient
  • Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON . See R2 <--> R3 Conversion Maps (status = 4 tests that all execute ok. All tests pass round-trip testing and 4 r3 resources are invalid (4 errors). ). for R4B as XML or JSON .

Structure

0..1 Unique id registered | Issue Category,
Name Flags Card. Type Description & Constraints      Filter: Filters doco
. . DetectedIssue N DomainResource Clinical issue with action

Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ 0..* Identifier Business identifier for the detected issue

. . . status ?! Σ 1..1 code preliminary | final | amended + entered-in-error | unknown | mitigated | processing-error
ObservationStatus Binding: Detected Issue Status ( Required )
. . . category Σ 0..* CodeableConcept 0..1 High level categorization of detected issue
Binding: Detected Issue Category ( Preferred )

. . . severity Σ 0..1 code CodeableConcept high | moderate | low
DetectedIssueSeverity Binding: Detected Issue Severity ( Required Preferred )
. . . patient subject Σ 0..1 Reference ( Patient | Group | Device | Location | Organization | Procedure | Practitioner | Medication | Substance | BiologicallyDerivedProduct | NutritionProduct ) Associated patient subject
. . date . encounter Σ 0..1 Reference ( Encounter ) Encounter the detected issue is part of
... identified[x] Σ 0..1 When detected issue occurred/is occurring
.... identifiedDateTime 0..1 dateTime When identified
. . . . identifiedPeriod Period
.... identifiedTiming Timing
. . . author Σ 0..1 Reference ( Patient | RelatedPerson | Practitioner | PractitionerRole | Device ) The provider or device that identified the issue
. . . implicated Σ 0..* Reference ( Any ) Problem resource

. . . evidence 0..* BackboneElement Supporting evidence

. . . . code 0..* CodeableConcept Manifestation
Binding: Manifestation and Symptom Codes ( Example )

.... detail 0..* 0..1 Reference ( Any ) Supporting information

string
. . . detail 0..1 markdown Description and context
. . . reference 0..1 uri Authority for issue
. . mitigation . qualityOfEvidence 0..1 CodeableConcept The quality of the evidence supporting the detected issue
Binding: QualityOfEvidenceRating icon ( Example )
... expectedOnsetType 0..1 CodeableConcept Time frame of clinical effect
Binding: Detected Issue Expected Onset Type ( Example )
... medicationClass 0..* CodeableConcept BackboneElement What medication class
Binding: Detected Issue Example Medication Class ( Example )

. . . managementCode 0..1 CodeableConcept Importance of taking action on the issue
Binding: Detected Issue Management Code ( Example )
... mitigation 0..* BackboneElement Step taken to address

. . . . action 1..1 CodeableConcept What mitigation?
Binding: Detected Issue Mitigation Action ( Preferred )
. . . . date 0..1 dateTime Date committed
. . . . author 0..1 Reference ( Practitioner | PractitionerRole ) Who is committing?
. . . . note 0..* Annotation Additional notes about the mitigation


doco Documentation for this format icon

See the Extensions for this resource

UML Diagram ( Legend )

DetectedIssue ( DomainResource ) Business identifier associated with the identifiers assigned to this detected issue record by the performer and/or other systems. These identifiers remain constant as the resource is updated and propagates from server to server identifier : Identifier [0..1] [0..*] Indicates the status The current state of the detected issue (this element modifies the meaning of other elements) status : code [1..1] « Indicates the status of the identified issue null (Strength=Required) ObservationStatus DetectedIssueStatus ! » Identifies Partitions the general type of detected issue identified into one or more categories that can be used to filter searching, to govern access control and/or to guide system behavior category : CodeableConcept [0..1] [0..*] « Codes identifying null (Strength=Preferred) DetectedIssueCategory ? » A code that identifies the general specific type of issue detected issue; e.g. Drug-drug interaction, Timing issue, Duplicate therapy, etc. code : CodeableConcept [0..1] « null (Strength=Preferred) Detected Issue Category DetectedIssueCode ? » Indicates the degree of importance associated with the identified issue based on the potential impact on the patient severity : code CodeableConcept [0..1] « Indicates the potential degree of impact of the identified issue on the patient. (Strength=Required) null (Strength=Preferred) DetectedIssueSeverity ! ? » Indicates the patient subject whose record the detected issue is associated with patient subject : Reference [0..1] « Patient | Group | Device | Location | Organization | Procedure | Practitioner | Medication | Substance | BiologicallyDerivedProduct | NutritionProduct » The date Encounter during which this detected issue was created or date-time to which the creation of this record is tightly associated encounter : Reference [0..1] « Encounter » The date, period or timing when the detected issue was initially identified did occur or is occurring date identified[x] : dateTime DataType [0..1] « dateTime | Period | Timing » Individual or device responsible for the issue being raised. For example, a decision support application or a pharmacist conducting a medication review author : Reference [0..1] « Patient | RelatedPerson | Practitioner | PractitionerRole | Device » Indicates the resource representing the current activity or proposed activity that is potentially problematic implicated : Reference [0..*] « Any » A textual explanation of the detected issue detail : string markdown [0..1] The literature, knowledge-base or similar reference that describes the propensity for the detected issue identified reference : uri [0..1] The quality of the evidence supporting identification of the detected issue. The code system used specifies the quality scale used to grade this evidence source while the code specifies the actual quality score (represented as a coded value) associated with the evidence qualityOfEvidence : CodeableConcept [0..1] « null (Strength=Example) QualityOfEvidenceRating ?? » The time frame in which the clinical effects of the detected issue may be expected to occur. Rapid refers to an expected onset within 24 hours. Delayed refers to an expected onset in more than 24 hours expectedOnsetType : CodeableConcept [0..1] « null (Strength=Example) DetectedIssueExpectedOnsetType ?? » Represents the medication class that is responsible for the detected issue medicationClass : CodeableConcept [0..*] « null (Strength=Example) DetectedIssueExampleMedicatio... ?? » An indication of the importance or type of step that should or may be taken in order to address the detected issue. This is different than mitigation in that it is not specifically providing actions to be taken, rather general suggestions about approach managementCode : CodeableConcept [0..1] « null (Strength=Example) DetectedIssueManagementCode ?? » Evidence A manifestation that led to the recording of this detected issue code : CodeableConcept [0..*] « null (Strength=Example) ManifestationAndSymptomCodes ?? » Links to resources that constitute evidence for the detected issue such as a GuidanceResponse or MeasureReport detail : Reference [0..*] « Any » Mitigation Describes the action that was taken or the observation that was made that reduces/eliminates the risk associated with the identified issue action : CodeableConcept [1..1] « Codes describing steps taken to resolve the issue or other circumstances that mitigate the risk associated with the issue; e.g. 'added concurrent therapy', 'prior therapy documented', etc. null (Strength=Preferred) Detected Issue Mitigation Act... DetectedIssueMitigationAction ? » Indicates when the mitigating action was documented date : dateTime [0..1] Identifies the practitioner who determined the mitigation and takes responsibility for the mitigation step occurring author : Reference [0..1] « Practitioner | PractitionerRole » Clinicians may add additional notes or justifications about the mitigation action. For example, patient can have this drug because they have had it before without any issues. Multiple justifications may be provided note : Annotation [0..*] Supporting evidence or manifestations that provide the basis for identifying the detected issue such as a GuidanceResponse or MeasureReport evidence [0..*] Indicates an action that has been taken or is committed to 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 [0..*]

XML Template 

<

<DetectedIssue xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <
 <</category>
 <
 <</patient>
 <
 <</author>

 <identifier><!-- 0..* Identifier Business identifier for detected issue --></identifier>
 <status value="[code]"/><!-- 1..1 preliminary | final | entered-in-error | unknown | mitigated | processing-error -->
 <category><!-- 0..* CodeableConcept High level categorization of detected issue --></category>
 <code><!-- 0..1 CodeableConcept Specific type of detected issue, e.g. drug-drug, duplicate therapy, etc --></code>
 <severity><!-- 0..1 CodeableConcept high | moderate | low --></severity>
 <subject><!-- 0..1 Reference(BiologicallyDerivedProduct|Device|Group|Location|
   Medication|NutritionProduct|Organization|Patient|Practitioner|Procedure|
   Substance) Associated subject --></subject>

 <encounter><!-- 0..1 Reference(Encounter) Encounter the detected issue is part of --></encounter>
 <identified[x]><!-- 0..1 dateTime|Period|Timing When detected issue occurred/is occurring --></identified[x]>
 <author><!-- 0..1 Reference(Device|Patient|Practitioner|PractitionerRole|
   RelatedPerson) The provider or device that identified the issue --></author>
 <implicated><!-- 0..* Reference(Any) Problem resource --></implicated>
 <
 <
 <

 <evidence>  <!-- 0..* Supporting evidence -->
  <code><!-- 0..* CodeableConcept Manifestation --></code>
  <detail><!-- 0..* Reference(Any) Supporting information --></detail>
 </evidence>
 <detail value="[markdown]"/><!-- 0..1 Description and context -->
 <reference value="[uri]"/><!-- 0..1 Authority for issue -->
 <qualityOfEvidence><!-- 0..1 CodeableConcept The quality of the evidence supporting the detected issue icon --></qualityOfEvidence>
 <expectedOnsetType><!-- 0..1 CodeableConcept Time frame of clinical effect --></expectedOnsetType>
 <medicationClass><!-- 0..* CodeableConcept What medication class --></medicationClass>
 <managementCode><!-- 0..1 CodeableConcept Importance of taking action on the issue --></managementCode>
 <mitigation>  <!-- 0..* Step taken to address -->

  <action><!-- 1..1 CodeableConcept What mitigation? --></action>
  <
  <</author>

  <date value="[dateTime]"/><!-- 0..1 Date committed -->
  <author><!-- 0..1 Reference(Practitioner|PractitionerRole) Who is committing? --></author>
  <note><!-- 0..* Annotation Additional notes about the mitigation --></note>

 </mitigation>
</DetectedIssue>

JSON Template 

{doco
  "resourceType" : "",

  "resourceType" : "DetectedIssue",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
    "
    "
    "

  "identifier" : [{ Identifier }], // Business identifier for detected issue
  "status" : "<code>", // R!  preliminary | final | entered-in-error | unknown | mitigated | processing-error
  "category" : [{ CodeableConcept }], // High level categorization of detected issue
  "code" : { CodeableConcept }, // Specific type of detected issue, e.g. drug-drug, duplicate therapy, etc
  "severity" : { CodeableConcept }, // high | moderate | low
  "subject" : { Reference(BiologicallyDerivedProduct|Device|Group|Location|
   Medication|NutritionProduct|Organization|Patient|Practitioner|Procedure|
   Substance) }, // Associated subject

  "encounter" : { Reference(Encounter) }, // Encounter the detected issue is part of
  // identified[x]: When detected issue occurred/is occurring. One of these 3:

  "identifiedDateTime" : "<dateTime>",
  "identifiedPeriod" : { Period },
  "identifiedTiming" : { Timing },
  "author" : { Reference(Device|Patient|Practitioner|PractitionerRole|
   RelatedPerson) }, // The provider or device that identified the issue

  "implicated" : [{ Reference(Any) }], // Problem resource
  "evidence" : [{ // Supporting evidence
    "code" : [{ CodeableConcept }], // Manifestation
    "detail" : [{ Reference(Any) }] // Supporting information
  }],
  "detail" : "<markdown>", // Description and context
  "reference" : "<uri>", // Authority for issue
  "qualityOfEvidence" : { CodeableConcept }, // The quality of the evidence supporting the detected issue icon
  "expectedOnsetType" : { CodeableConcept }, // Time frame of clinical effect
  "medicationClass" : [{ CodeableConcept }], // What medication class
  "managementCode" : { CodeableConcept }, // Importance of taking action on the issue
  "mitigation" : [{ // Step taken to address
    "action" : { CodeableConcept }, // R!  What mitigation?
    "date" : "<dateTime>", // Date committed
    "author" : { Reference(Practitioner|PractitionerRole) }, // Who is committing?
    "note" : [{ Annotation }] // Additional notes about the mitigation

  }]
}

Turtle Template 

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:;

[ a fhir:DetectedIssue;

  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from 
  # from 
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
  ], ...;

  # from Resource: fhir:id, fhir:meta, fhir:implicitRules, and fhir:language
  # from DomainResource: fhir:text, fhir:contained, fhir:extension, and fhir:modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business identifier for detected issue
  fhir:status [ code ] ; # 1..1 preliminary | final | entered-in-error | unknown | mitigated | processing-error
  fhir:category  ( [ CodeableConcept ] ... ) ; # 0..* High level categorization of detected issue
  fhir:code [ CodeableConcept ] ; # 0..1 Specific type of detected issue, e.g. drug-drug, duplicate therapy, etc
  fhir:severity [ CodeableConcept ] ; # 0..1 high | moderate | low
  fhir:subject [ Reference(BiologicallyDerivedProduct|Device|Group|Location|Medication|NutritionProduct|
  Organization|Patient|Practitioner|Procedure|Substance) ] ; # 0..1 Associated subject

  fhir:encounter [ Reference(Encounter) ] ; # 0..1 Encounter the detected issue is part of
  # identified[x] : 0..1 When detected issue occurred/is occurring. One of these 3
    fhir:identified [  a fhir:DateTime ; dateTime ]
    fhir:identified [  a fhir:Period ; Period ]
    fhir:identified [  a fhir:Timing ; Timing ]
  fhir:author [ Reference(Device|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 The provider or device that identified the issue
  fhir:implicated  ( [ Reference(Any) ] ... ) ; # 0..* Problem resource
  fhir:evidence ( [ # 0..* Supporting evidence
    fhir:code  ( [ CodeableConcept ] ... ) ; # 0..* Manifestation
    fhir:detail  ( [ Reference(Any) ] ... ) ; # 0..* Supporting information
  ] ... ) ;
  fhir:detail [ markdown ] ; # 0..1 Description and context
  fhir:reference [ uri ] ; # 0..1 Authority for issue
  fhir:qualityOfEvidence [ CodeableConcept ] ; # 0..1 The quality of the evidence supporting the detected issue
  fhir:expectedOnsetType [ CodeableConcept ] ; # 0..1 Time frame of clinical effect
  fhir:medicationClass  ( [ CodeableConcept ] ... ) ; # 0..* What medication class
  fhir:managementCode [ CodeableConcept ] ; # 0..1 Importance of taking action on the issue
  fhir:mitigation ( [ # 0..* Step taken to address
    fhir:action [ CodeableConcept ] ; # 1..1 What mitigation?
    fhir:date [ dateTime ] ; # 0..1 Date committed
    fhir:author [ Reference(Practitioner|PractitionerRole) ] ; # 0..1 Who is committing?
    fhir:note  ( [ Annotation ] ... ) ; # 0..* Additional notes about the mitigation
  ] ... ) ;

]

Changes since DSTU2 from both R4 and R4B

DetectedIssue
DetectedIssue.status
  • Change value set from http://hl7.org/fhir/ValueSet/observation-status|4.0.0 to Detected Issue Status
  • Remove codes registered , amended , corrected , cancelled
  • Add code mitigated
DetectedIssue.category
  • Added Element
DetectedIssue.severity
  • Type changed from code to CodeableConcept
  • Remove Binding `http://hl7.org/fhir/ValueSet/detectedissue-severity|4.0.0` (required)
DetectedIssue.subject
  • Added Element
DetectedIssue.encounter
  • Added Element
DetectedIssue.identified[x]
  • Add Type Timing
DetectedIssue.author
  • Type Reference: Added Target Types Patient, RelatedPerson
DetectedIssue.detail
  • Type changed from string to markdown
DetectedIssue.qualityOfEvidence
  • Added Element
DetectedIssue.expectedOnsetType
  • Added Element
DetectedIssue.medicationClass
  • Added Element
DetectedIssue.managementCode
  • Added Element
DetectedIssue.mitigation.note
  • Added Element
DetectedIssue.patient
  • Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON . See R2 <--> R3 Conversion Maps (status = 4 tests that all execute ok. All tests pass round-trip testing and 4 r3 resources are invalid (4 errors). ). for R4B as XML or JSON .

 

Alternate Additional definitions: Master Definition ( XML , + JSON ), , XML Schema / Schematron (for ) + JSON Schema , ShEx (for Turtle ) + see the extensions , the spreadsheet version & the dependency analysis

9.10.4.1 9.9.5.1 Terminology Bindings

DetectedIssue.mitigation.action
Path Definition ValueSet Type Reference Documentation
DetectedIssue.status Indicates the status of the identified issue DetectedIssueStatus Required ObservationStatus

Indicates the status of a detected issue

DetectedIssue.category DetectedIssueCategory Preferred Codes identifying the general type

Kinds of detected issue; e.g. Drug-drug interaction, Timing issue, Duplicate therapy, issues or contraindications, such as 'drug-drug interaction', 'duplicate therapy', etc.

DetectedIssue.code DetectedIssueCode Preferred Detected Issue Category

Codes for issues or contraindications, such as 'drug-drug interaction', 'duplicate therapy', etc.

DetectedIssue.severity DetectedIssueSeverity Preferred

Indicates the potential degree of impact of the identified issue on the patient.

DetectedIssue.evidence.code ManifestationAndSymptomCodes Required Example DetectedIssueSeverity

Example value set for Manifestation and Symptom codes.

DetectedIssue.qualityOfEvidence QualityOfEvidenceRating icon Example Codes describing steps taken to resolve the issue or other circumstances

A rating system that mitigate describes the risk associated with quality of evidence such as the issue; e.g. 'added concurrent therapy', 'prior therapy documented', etc. GRADE, DynaMed, or Oxford CEBM systems.

DetectedIssue.expectedOnsetType DetectedIssueExpectedOnsetType Preferred Example

Example value set illustrating the expected onset type.

DetectedIssue.medicationClass DetectedIssueExampleMedicationClass Example

Example value set illustrating medication classes.

DetectedIssue.managementCode DetectedIssueManagementCode Example

Example value set illustrating the type action (management) required.

DetectedIssue.mitigation.action Detected Issue Mitigation Action DetectedIssueMitigationAction Preferred

Kinds of mitigating actions and observations that can be associated with a detected issue or contraindication, such as 'added concurrent therapy', 'prior therapy documented', etc.

9.10.5 9.9.6 Linking to Detected Issues

DetectedIssue follows the pattern of linking from the resource created "second". "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" "owned" by the record whose creation triggers the contraindication being created - i.e. the "second" "second" or "last" "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.

9.10.6 9.9.7 Workflow Challenges

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.

9.10.7 9.9.8 Open Issues

  • Are author, reference and/or mitigation (and its various parts) all part of the 80%?

9.10.8 9.9.9 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource , and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
author reference The provider or device that identified the issue DetectedIssue.author
( Practitioner , Device , Patient , PractitionerRole , RelatedPerson )
category token Issue Category, e.g. drug-drug, duplicate therapy, etc. DetectedIssue.category
code token date Issue Type, e.g. drug-drug, duplicate therapy, etc. DetectedIssue.code 19 Resources
identified date When identified DetectedIssue.date DetectedIssue.identified.ofType(dateTime) | DetectedIssue.identified.ofType(Period) 18 Resources
identifier token Unique id for the detected issue DetectedIssue.identifier 26 58 Resources
implicated reference Problem resource DetectedIssue.implicated
(Any)
patient reference Associated patient DetectedIssue.patient DetectedIssue.subject.where(resolve() is Patient)
( Patient ) 		31 60 Resources
status token The status of the issue DetectedIssue.status
subject reference Associated subject DetectedIssue.subject
( Practitioner , Group , Organization , BiologicallyDerivedProduct , NutritionProduct , Device , Medication , Patient , Procedure , Substance , Location )