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  • A ClinicalImpresssion:

    • .finding for each .component in the observation (e.g. systolic and diastolic blood pressure) or a single finding if the observation does not contain components.

      • Each finding for observation will have one of the following alert levels:

        • http://snomed.info/sct, 442082004, fund ved måling inden for referenceinterval (green)

        • http://snomed.info/sct, 442096005, fund ved måling uden for referenceinterval (red, yellow)

      • If the finding is for a component, then it will contain an observation code identifying the component (e.g. systolic blood pressure)

      A Task related to the ClinicalImpression with priority based on the highest alert level found:

      • asap if any values are found in .

    • .finding for the overall assessment which is either green, yellow or red based on the worst severity from components or a single observation, see green, yellow and red in .https://ehealth.sundhed.dk/fhir/ValueSet-ehealth-clinicalimpression-finding-codes.html .

    • A Task related to the ClinicalImpression with priority based on the highest alert level found:

      • asap if any values are found in “red alert” reference ranges

      • urgent if any values are found in “yellow alert” reference ranges (and no “red alert” found)

      • routine if no red or yellow alerts are found

...

The rule processes absolute reference ranges only, that is, Observation.referenceRange.type where the Coding has:

  • system: urn:oid:1.2.208.184.100.1

  • code: RAL or GAL, for red alarm absolute reference range and yellow alarm absolute reference range, respectively.

...

The rule accepts observation values and reference ranges without units. However if both have a unit specified, they must match.

Assessment of Relative Reference Ranges Library and Rule

This Library is similar to the Absolute Reference Range library (see above) in some aspects: Input and output are identical. The difference is the the type of reference ranges that the rule handles. Absolute and relative reference range libraries can co-exist and can both process the same Observation. They will each handle their corresponding type of reference ranges associated with the Observation.

The rule processes relative reference ranges only, that is, Observation.referenceRange.type where the Coding has:

...

Error handling for different situations which result in the rule setting up instructions for creation of one or two Task:

Situation

Generic Task

Possible Specific Task (Stating what was wrong)

No absolute reference range found

Task (Stating that measurement needs manual assessment):

  • .category with .code = MeasurementForAssessment, .system = http://ehealth.sundhed.dk/cs/

...

code: RELRAL or RELGAL, for red alarm relative reference range and yellow alarm relative reference range, respectively.

A vital difference from the rule in the Absolute Reference Range Library is that Relative Reference Range Library rule must have a reference base to compare against.

A relative reference range can be stated:

  • in same unit as the Observation

  • as a percentage or, in case the Observation is already expressed with unit percentage (as is the case for oxygen saturation, for instance), as a percentage point.

...

Example relative reference range as -5 percentage point with reference base 90% for oxygen saturation measurement

The oxygen saturation measurement unit is expressed as percent (system=http://unitsofmeasure.org, code=%), the reference base likewise and in this case with a value of 90.

A red alarm relative reference range given as -5 percentage point would be given by a SimpleQuantity for the reference range’s low element with:

...

value=-5

...

unit=percentage point

  • task-category, .display = Need assessment of measurement

  • .description = Måling til vurdering

  • .restrictionCategory with .code = measurement-monitoring, system = http://ehealth.sundhed.dk/cs/restriction-category, .display = Monitoring of measurement(s)

  • .priority = routine

  • .focus = reference to measurement being processed, for instance Observation, QuestionnaireResponse or Media

No additional task.

Unit mismatch between reference range and observation value

Task (Stating that measurement needs manual assessment as auto processing failed):

  • .category with .code = MeasurementForAssessmentFailureInAutoProcessing, .system = http://ehealth.sundhed.dk/cs/task-category, .display = Measurement Assessment failure during automated processing

  • .description = Vurdering af måling er fejlet under automatisk behandling

  • .restrictionCategory with .code = measurement-monitoring, system = http://ehealth.sundhed.dk/cs/restriction-category, .display = Monitoring of measurement(s)

  • .priority = routine

  • .focus = reference to measurement being processed, for instance Observation, QuestionnaireResponse or Media

Task:

  • .category with .code = RefRangeFixingNeeded, .system = http://ehealth.sundhed.dk/cs/

...

code=percentagepoint

Thus, the rule would treat an Observation with value 85% as a red alarm case for this relative reference range and current choice of reference base with value 90%.

The rule handles situations as follows:

Situation

Handling by setting up instructions causing creation of Task

Neither reference base nor relative reference range(s) found

Task:

.category with .code = MeasurementForAssessmentNotTriaged, .

  • task-category, .display = Missing in force reference base required for automatic processing

  • .description = Automatiseret behandling af måledata fejlede. Grænseværdi krævet af automatiseret behandling skal udbedres

  • .restrictionCategory with .code = measurement-monitoring, system = http://ehealth.sundhed.dk/cs/

task

  • .description = Måling til vurdering, hvor triagering ikke er udført af automatiseret behandling

    • .restrictionCategory with .code = measurement-monitoring,

    • restriction-category, .display =

    Need assessment of measurement where triage was not performed during automated processing

    No reference base found

    • Monitoring of measurement(s)

    • .priority = routine

    • .focus = reference to ServiceRequest referenced by the measurement being processed

    Missing observation value

    Task (Stating that measurement needs manual assessment as auto processing failed):

    • .category with .code = MeasurementForAssessmentFailureInAutoProcessing, .system = http://ehealth.sundhed.dk/cs/task-category, .display = Measurement Assessment failure during automated processing

    • .description = Vurdering af måling er fejlet under automatisk behandling

    • .restrictionCategory with .code = measurement-monitoring, system = http://ehealth.sundhed.dk/cs/restriction-category, .display = Monitoring of measurement(s)

    • .priority = routine

    • .focus = reference to measurement being processed, for instance Observation, QuestionnaireResponse or Media

    No additional task.

    Task:

    • .category with .code =

    RefBaseNeeded

    • LibraryUseMismatchFixingNeeded, .system = http://ehealth.sundhed.dk/cs/task-category, .display =

    Missing in force reference base required for automatic processing

    • Input and rule did not match

    • .description =

    Mangler gældende referenceværdi påkrævet for automatisk behandling

    • Automatiseret behandling af måledata fejlede. Aktivitet i plan og tilknyttet regel passer ikke sammen. Det bør overvejes om borger skal have ny plan.

    • .restrictionCategory with .code = measurement-monitoring, system = http://ehealth.sundhed.dk/cs/restriction-category, .display = Monitoring of measurement(s)

    • .priority = routine

    • .focus = reference to ServiceRequest referenced by the measurement being processed

    No relative reference range found

    Task:

  • .category with .code = RefRangeNeeded, .system = http://ehealth.sundhed.dk/cs/task-category, .display = Missing reference range required for automated processing

  • .description = Mangler grænseværdi påkrævet for automatisk behandling

    • .restrictionCategory with .code = measurement-monitoring, system =

    Assessment of Relative Reference Ranges Library and Rule

    This Library is similar to the Absolute Reference Range library (see above) in some aspects: Input and output are identical. The difference is the the type of reference ranges that the rule handles. Absolute and relative reference range libraries can co-exist and can both process the same Observation. They will each handle their corresponding type of reference ranges associated with the Observation.

    The rule processes relative reference ranges only, that is, Observation.referenceRange.type where the Coding has:

    • system: http://ehealth.sundhed.dk/cs/

    ...

    .priority = routine

    ...

    .focus = reference to ServiceRequest referenced by the measurement being processed

    Library for Assessment of Questionnaire Response

    This Library contains a generic rule that performs assessment of a QuestionnaireResponse in relation to any answer significances defined in the corresponding Questionnaire.

    ...

    • reference-range-type

    • code: RELRAL or RELGAL, for red alarm relative reference range and yellow alarm relative reference range, respectively.

    A vital difference from the rule in the Absolute Reference Range Library is that Relative Reference Range Library rule must have a reference base to compare against.

    A relative reference range can be stated:

    • in same unit as the Observation

    • as a percentage or, in case the Observation is already expressed with unit percentage (as is the case for oxygen saturation, for instance), as a percentage point.

    Info

    Example relative reference range as -5 percentage point with reference base 90% for oxygen saturation measurement

    The oxygen saturation measurement unit is expressed as percent (system=http://unitsofmeasure.org, code=%), the reference base likewise and in this case with a value of 90.

    A red alarm relative reference range given as -5 percentage point would be given by a SimpleQuantity for the reference range’s low element with:

    • value=-5

    • unit=percentage point

    • system=http://ehealth.sundhed.dk/cs/ehealth-unit-code

    • code=percentagepoint

    Thus, the rule would treat an Observation with value 85% as a red alarm case for this relative reference range and current choice of reference base with value 90%.

    The rule handles different situations which result in the rule setting up instructions for creation of one or two Task:

    Situation

    Generic Task

    Possible Specific Task (Stating what was wrong)

    Neither reference base nor relative reference range(s) found

    Task:

    • .category with .code = MeasurementForAssessmentNotTriaged, .system = http://ehealth.sundhed.dk/cs/task-category, .display = Need assessment of measurement where triage was not performed during automated processing

    • .description = Måling til vurdering, hvor triagering ikke er udført af automatiseret behandling

    • .restrictionCategory with .code = measurement-monitoring, system = http://ehealth.sundhed.dk/cs/restriction-category, .display = Monitoring of measurement(s)

    • .priority = routine

    • .focus = reference to measurement being processed, for instance Observation, QuestionnaireResponse or Media

    No additional task.

    No reference base found

    Task:

    • .category with .code = RefBaseNeeded, .system = http://ehealth.sundhed.dk/cs/task-category, .display = Missing in force reference base required for automatic processing

    • .description = Mangler gældende referenceværdi påkrævet for automatisk behandling

    • .restrictionCategory with .code = measurement-monitoring, system = http://ehealth.sundhed.dk/cs/restriction-category, .display = Monitoring of measurement(s)

    • .priority = routine

    • .focus = reference to ServiceRequest referenced by the measurement being processed

    No relative reference range found

    Task:

    • .category with .code = RefRangeNeeded, .system = http://ehealth.sundhed.dk/cs/task-category, .display = Missing reference range required for automated processing

    • .description = Mangler grænseværdi påkrævet for automatisk behandling

    • .restrictionCategory with .code = measurement-monitoring, system = http://ehealth.sundhed.dk/cs/restriction-category, .display = Monitoring of measurement(s)

    • .priority = routine

    • .focus = reference to ServiceRequest referenced by the measurement being processed

    Library for Assessment of Questionnaire Response

    This Library contains a generic rule that performs assessment of a QuestionnaireResponse in relation to any answer significances defined in the corresponding Questionnaire.

    During processing of the rule, each answer significance defined in the Questionnaire (see https://ehealth.sundhed.dk/fhir/StructureDefinition-ehealth-questionnaire.html#answer-significance ) on questions and their linked answers in the QuestionnaireResponse are traversed and checked whether the condition(s) of the answer significance is met by the linked answer. When this is the case, a finding basis is added to internal bookkeeping. Ultimately, the list of finding basis determines the created ClinicalImpression finding and the priority of the created task:

    ...

    • A ClinicalImpresssion:

      • .finding as follows:

        • If the triggered red set is not empty, a finding.item with a Coding:

          • system = http://ehealth.sundhed.dk/cs/clinicalimpression-finding-codes

          • code = red-question-answer

          • display = Rød spørgsmål/svar-kombination fundet i spørgeskemabesvarelse

          If the triggered yellow set is not

          • display = Red overall assessment

        • If the triggered yellow set is not empty, a finding.item with a Coding:

          • system = http://ehealth.sundhed.dk/cs/clinicalimpression-finding-codes

          • code = yellow

          • display = yellow overall assessment

        • If both triggered sets are empty, a finding.item with a Coding:

          • system = http://ehealth.sundhed.dk/cs/clinicalimpression-finding-codes

          • code = yellow-question-answer green

          • display = Gul spørgsmål/svar-kombination fundet i spørgeskemabesvarelse

          If both triggered sets are empty

          • Green overall assessment

        • If the Questionnaire does contain answer significance definitions but none have been triggered, a finding.item with a Coding:

          • system = http://ehealth.sundhed.dk/cs/clinicalimpression-finding-codes

          • code = greenno-questioneffective-answer-significance

          • display = Grøn Ingen triageringsindikator for spørgsmål/svar-kombination har fundet i spørgeskemabesvarelseanvendelse

        • If the Questionnaire does not contain answer significance definitions but none have been triggereddefinitions, a finding.item with a Coding:

          • system = http://ehealth.sundhed.dk/cs/clinicalimpression-finding-codes

          • code = no-effective-answer-significance-defined

          • display = Ingen triageringsindikator for spørgsmål/svar-kombination har fundet anvendelse

          If the Questionnaire does not contain answer significance definitions, a finding.item with a Coding:

          • system = defineret i spørgeskemaet

      • list of .ehealth-questionnaireresponse-finding-basis for each basis for the overall ClinicalImpression as follows:

        priority set to the priority value determined above

        • linkId set to linkId for the Questionnaire item/QuestionnaireResponse item pair which triggered the finding basis

        • value set to value of the answer which triggered the finding basis

        • finding set to green-question-answer, yellow-question-answer or red-question-answer from http://ehealth.sundhed.dk/

          cs

          vs/clinicalimpression-finding-codes

        • code = no-answer-significance-defined

        • display = Ingen triageringsindikator defineret i spørgeskemaet

      • list of .ehealth-questionnaireresponse-finding-basis for each basis for the overall ClinicalImpression as follows:

        • linkId set to linkId for the Questionnaire item/QuestionnaireResponse item pair which triggered the finding basis

        • value set to value of the answer which triggered the finding basis

        • finding set to green-question-answer, yellow-question-answer or red-question-answer from http://ehealth.sundhed.dk/vs/clinicalimpression-finding-codes based on signifiance on triggered ehealth-questionnaire-answerSignificance

        • ehealth-questionnaire-answerSignificance gathered from Questionnaire item

      A Task related to the ClinicalImpression with:

        • based on signifiance on triggered ehealth-questionnaire-answerSignificance

        • ehealth-questionnaire-answerSignificance is the triggered answerSignificance which is gathered from Questionnaire item

    • A Task related to the ClinicalImpression with:

      • priority set to the priority value determined above.

    A difference between the finding in finding.item.code and the finding basis in ehealth-questionnaire-finding-basis is that the former is a conclusion or summary while the latter provides the details that led to the conclusion. In ehealth-questionnaire-finding-basis there may be multiple entries for the same question-answer pair and those entries may or may not have the same significance (color). That depends on the how the answer (or lack of answer) fits with answer significance definitions in the Questionnaire.

    Assessment of TeleCare Nord COPD Questionnaire

    ...

    ...

    Output will be a code from the http://hl7.org/fhir/v3/ObservationInterpretation CodeSystem:

    Output Coding

    Evaluation

    code=IND, system=http://hl7.org/fhir/v3/ObservationInterpretation, display=Indeterminate

    The referenced ServiceRequest does not contain ehealth-reuseCriteria specifying a max age of the height Observation. This max age, although stated for reuse, is used for the height Observation use in an BMI calculation also.

    code=N, system=http://hl7.org/fhir/v3/ObservationInterpretation, display=Normal

    The height Observation has not exceeded the max age specified in ehealth-reuseCriteria in the referenced ServiceRequest.

    code=L, system=http://hl7.org/fhir/v3/ObservationInterpretation, display=Low

    The height Observation has exceeded the max age specified in ehealth-reuseCriteria in the referenced ServiceRequest.

    Library for Calculating Body Mass Index

    ...

    It is not necessary to provide the ServiceRequest as input. The Libary$evaluate operation will retrieve it by resolving the basedOn reference in the weight Observation.

    ...