1 Performing Document Query and Document Retrieve
2 Provided Transformations between FHIR resources and Danish CDA Profiles
3 Preparing Transformations by Assembling Required FHIR Resources
- 3.1 Assembling FHIR Resources for Transformation to PHMR
- 3.2 Assembling FHIR Resources for Transformation to QRD
4 Transformation Details

The eHealth Infrastructure provides integrations to the Danish national document sharing infrastructure.

The national document sharing infrastructure is based on Integrating the Health Enterprise (IHE) Cross-enterprise Document Sharing (XDS-b) profiles and makes use of Danish profiles for document metadata. While XDS-b is content-agnostic, currently shared documents are XML documents (ideally) adhering to Danish profiles of Clinical Document Architecture (CDA) document types.

Queries for document metadata and retrieve of documents can be performed through the healthcare domain National Service Platform (NSP) Document Sharing Service (Danish: Dokumentdelingsservice DDS). Acting as a front, the DDS encapsulates details about the topology of XDS-b components, whether this is one or more XDS Registry containing document metadata or one or more XDS Repository containing documents.

The eHealth Infrastructure:

Performs registering of measurement data to the KIH XDS Repository (see Registering of documents)
Performs registering of appointments to the XDS Repository fronted by NSP Document Registering and Update Service (see Registering of documents)
Provides a FHIR wrapping for performing querying for document metadata and retrieving documents on the NSP DDS (see Performing Document Query and Document Retrieve below)

The eHealth Infrastructure provides transformations between FHIR resources and Danish profiles of Clinical Document Architecture (CDA) XML documents. The transformations to CDA documents are used (see details below) when the eHealth infrastructure uploads documents and metadata to document sharing infrastructure . The transformations to FHIR resources can be used by a client performing XDS-b document metadata query and document retrieving.

Performing Document Query and Document Retrieve

The Danish National Service Platform (NSP) in Healthcare provides a Document Sharing Service (Danish: Dokumentdelingsservice DDS) which provides the following operations described in https://profiles.ihe.net/ITI/TF/Volume1/ch-10.html:

Registry Stored Query (known as XDS-b transaction ITI-18) which given query parameters such as patient identification and time period (and more), returns matching document metadata, possibly zero, one or more.
Retrieve Document Set (known as XDS-b transaction ITI-43) which given parameters identifying the document (based on document metadata), returns possibly zero, one or more documents.

Further details on how the NSP DDS processes ITI-18 and ITI-43 requests, including possibly withholding data due to patient’s consents (Danish: Min Spærring) are described in Danish at https://www.nspop.dk/x/WJC6.

Use of these operations is fronted by the following eHealth infrastructure operations provided by the document-query service:

DocumentReference?<query> (see https://docs.ehealth.sundhed.dk/latest-released/ig/ehealth-documentreference-search.html)
Binary/$retrieve-document (see https://docs.ehealth.sundhed.dk/latest-released/ig/OperationDefinition-Binary-t-retrieve-document.html)

Document metadata query is a precursor for actually retrieving a document.

While the XDS-b transaction ITI-43 Retrieve Document Set supports retrieval of multiple documents, the $retrieve-document supports retrieve of a single document only.

Provided Transformations between FHIR resources and Danish CDA Profiles

Details on the transformations are included in the table below containing references to Danish CDA profiles for which further details are given in the table further below.

The transformations are:

idempotent (except for generated identifiers such as CDA document id in output)
provide no access to any FHIR resources - they require that the client provides the necessary FHIR resources as input. This is by design in order to prevent security breach.

Transformation	Source (XML document in FHIR DocumentReference)	Target (XML document in FHIR DocumentReference)	Comment

Transformation	Source (XML document in FHIR DocumentReference)	Target (XML document in FHIR DocumentReference)	Comment
`$transform-to-PHMR`	Bundle of FHIR resources. Primary source of information is a FHIR Observation.	PHMR v1.3 XML document.	Used in assembly, transformation and upload of FHIR Observation transformed to PHMR to XDS-based document sharing infrastructure as described in Sharing through Registering Documents in National Document Sharing Infrastructure.
`$transform-to-QRD`	Bundle of FHIR resources. Primary source of information is a FHIR QuestionnaireResponse.	QRD v1.3 XML document	Used in assembly, transformation and upload of FHIR QuestionnaireResponse transformed to QRD to XDS-based document sharing infrastructure as described in Sharing through Registering Documents in National Document Sharing Infrastructure.
`$transform-to-QFDD`	Bundle of FHIR resources. Primary source of information is a FHIR Questionnaire.	QFDD v1.1 XML document
`$transform-to-APD`	Bundle of FHIR resources. Primary source of information is a FHIR Appointment.	APD v2.0 XML document	Used in assembly, transformation and upload of FHIR Appointment transformed to APD to XDS-based document sharing infrastructure as described in Sharing through Registering Documents in National Document Sharing Infrastructure.
`$transform-from-PHMR`	PHMR v1.3 XML document.	Bundle of FHIR resources. Most significant information is within a FHIR Observation.	The resulting Observation(s) is not guaranteed to be a valid FHIR Observation.
`$transform-from-QRD`	QRD v1.3 XML document	Bundle of FHIR resources. Most significant information is within a FHIR QuestionnaireResponse.	The resulting QuestionnaireResponse is not guaranteed to be a valid FHIR QuestionnaireResponse.
`$transform-from-QRD-based-on-questionnaire` Please note that the description of the operation is valid as of v3.0.0 of the eHealth Infrastructure Implementation Guide (IG) even though the link is to the IG continuous build. Please refer to the latest released version of the IG for all other purposes.	QRD v1.3 XML document	Bundle of FHIR resources Most significant information is within a FHIR QuestionnaireResponse with a structure matching the Questionnaire given as input. The QuestionnaireResponse will have linkIds matching the corresponding Questionnnaire.	The resulting QuestionnaireResponse is not guaranteed to be a valid FHIR QuestionnaireResponse.
`$transform-from-QFDD`	QFDD v1.1 XML document	Bundle of FHIR resources. Primary source of information is a FHIR Questionnaire.
`$transform-from-APD`	APD v2.0 XML document	Bundle of FHIR resources. Primary source of information is a FHIR Appointment.	The resulting Appointment is not guaranteed to be a valid FHIR Appointment.

HL7 DK CDA Profile	Description	Specification

HL7 DK CDA Profile	Description	Specification
PHMR v1.3	HL7 Implementation Guide for CDA Release 2.0, Personal Healthcare Monitoring Report (PHMR), (Danish profile – PHMR DK), Release 1.3 31. March 2014, Updated 24. April 2018	http://svn.medcom.dk/svn/releases/Standarder/HL7/PHMR/Dokumentation/PHMR-DK-Profile-v1.3.pdf (Note: The available v1.3 is now updated as per March 2, 2020)
QRD v1.3	HL7 Implementation Guide for CDA Release 2.0, Questionnaire Response Document, (Danish profile – DK QRD), Release 1.3 February 11th 2022	https://svn.medcom.dk/svn/drafts/Standarder/HL7/PRO/QRD/Dokumentation/DK-QRD-v1.3.pdf
QFDD v1.1	HL7 Implementation Guide for CDA Release 2.0, Questionnaire Form Definition Document, (Danish profile – DK QFDD), Draft, Release 1.1 May 19th 2015, Updated September 28th 2016	http://svn.medcom.dk/svn/releases/Standarder/HL7/PRO/QFDD/Dokumentation/DK-QFDD-v1.1.pdf (Note: The available v1.1 is now updated as per June 11, 2021)
APD v2.0	HL7 Implementation Guide for CDA Release 2.0, Appointment Document, (Danish profile – DK APD), Draft for Trial Use, Release 2.0 November 4th 2019	http://svn.medcom.dk/svn/releases/Standarder/HL7/Appointment/Dokumentation/DK-APD-v2.0.pdf

Preparing Transformations by Assembling Required FHIR Resources

As described above, the transformations to CDA XML documents require that the client provides all the required FHIR resources. What FHIR resources must be part of the assembled FHIR bundle depends on the transformation.

When the eHealth infrastructure assembles FHIR resources in order to transform and upload to XDS-based document sharing infrastructure, the assembled resources are fetched from the various eHealth services. Whether this is the case for a client’s possible use is up to the client, that is, they could in principle be provided as in-memory FHIR resources that are not stored in the infrastructure.

Assembling FHIR Resources for Transformation to PHMR

A FHIR Bundle in-memory is prepared with the resources described below, based on a ClinicalImpression approving document sharing of the FHIR Observation. Typically, the assembly (and subsequent transformation and upload) is triggered by creation of the ClinicalImpression, but might otherwise be triggered by a ServiceRequest update reflecting a Practitioner’s registering of the citizen’s decision to change sharing policy.

FHIR Resource	Logical Part in Transformation	Comment

FHIR Resource	Logical Part in Transformation	Comment
Observation (referenced from ClinicalImpression)	Observation Details	The Observation is the primary driver of the information contained in the generated PHMR document, including observation code, measured value, reference ranges and so on.
Observation (referenced from ClinicalImpression)	DocumentationOf (CDA Header)
Device (referenced from `Observation.device`)	Medical Equipment Section	Possible details about device(s) used.
Patient (referenced from `ClinicalImpression.subject`)	Patient Identification	Patient identifier (CPR-number), name (given & family), gender, birth date, telecom
EpisodeOfCare (referenced from `ClinicalImpression.episodeOfCare`)	See Author Organization below
Organization (referenced from `EpisodeOfCare.managingOrganization`)	Custodian Organization	SOR id, name, telecom, address
Practitioner (possibly referenced from `ClinicalImpression.assessor`)	Author, Author Individual
Organization (referenced from `ClinicalImpression.assessorOrganization`)	Author, Author Organization
Composition (created as part of the assembly)	Document header (CDA Header)	The FHIR Composition resource represents the document and has fixed values as follows: Document identifier `value` = randomUUID `system` = `urn:oid:` + OID value from `NamingSystem.uniqueId.value` (where `uniqueId.type` is `oid`) from eHealthIdentifier `assigner` = the value of `NamingSystem.publisher` in eHealthIdentifier title = “Hjemmemonitorering for “ + <Patient’s CPR identifier value date = ClinicalImpression.`effective[x]` if present, else now (time of assembly) attester is created if `episodeOfCare.caremanagerOrganization` is present with: mode set to `Composition.CompositionAttestationMode.LEGAL`, party set to `episodeOfCare.CareManagerOrganization` time set to time of assembly
Practitioner/Patient/RelatedPerson/Organization	Author of observation note	When the `Observation.note.author` contains a reference, the referenced resource needs to be present in the bundle.
Practitioner (possibly referenced from `Observation.performer`)	Observation performer	If the observation performer is of type Practitioner it must be included in the bundle.

Assembling FHIR Resources for Transformation to QRD

A FHIR Bundle in-memory is prepared with the resources described below, based on a ClinicalImpression approving document sharing of the FHIR QuestionnaireResponse. Typically, the assembly (and subsequent transformation and upload) is triggered by creation of the ClinicalImpression, but might otherwise be triggered by a ServiceRequest update reflecting a Practitioner’s registering of the citizen’s decision to change sharing policy.

FHIR Resource	Logical Part in Transformation	Comment

FHIR Resource	Logical Part in Transformation	Comment
QuestionnaireResponse (referenced from ClinicalImpression)	Question/answer details	The QuestionnaireResponse is the primary driver of the information contained in QRD.
QuestionnaireResponse (referenced from ClinicalImpression)	DocumentationOf (CDA Header)	effectiveTime = `QuestionnaireResponse.authored` (dateTime)
Patient (referenced from `ClinicalImpression.subject`)	Patient identification	identifier (CPR-number), name (given & family), gender, birth date, telecom
EpisodeOfCare (referenced from `ClinicalImpression.episodeOfCare`)	See Author Organization below
Organization (referenced from `EpisodeOfCare.managingOrganization`)	Custodian Organization	SOR id, name, telecom, address
Practitioner (referenced from `ClinicalImpression.assessor`)	Author Individual	A consequence is that the Practitioner will appear as working in context of the Author Organization (which is not necessarily the case).
Organization (referenced from `ClinicalImpression.assessorOrganization`)	Author organization	The the origin of this Organization is dependent on sharingApprovalPolicy in the `ServiceRequest` If sharing approval is `manual` this is the organization from the approvers context. If sharing approval is `automatic` this is the organization from either `CarePlan.author` or from `EpisodeOfCare.caremanagerOrganization` in that order. If the FHIR Organization has no SOR type identifier, it is checked if it contains a SOR-relation in `Organization.ehealth-organization-relatedTo`.
Composition (created as part of the assembly)	Document header (CDA Header)	FHIR Resource to represent document fixed values Document id value=randomUUID system=”urn:oid: + OID value from `NamingSystem.uniqueId.value` (where `uniqueId.type` is `oid`) from eHealthIdentifier assigner: the value of `NamingSystem.publisher` in eHealthIdentifier title = same as `Questionnaire.title` effectiveTime = now (time of assembly)
Questionnaire (referenced from `QuestionnaireResponse.questionnaire`)	Used in Document header (CDA Header) above	`Questionnaire.identifier` must contain the unique QFDD document id: `Identifier.system` set to `urn:oid:` + <Attribute `root` in QFDD /ClinicalDocument/id> `Identifier.value` set to <Attribute `extension` in QFDD /ClinicalDocument/id> Note on prerequisites for document registering: The QFDD must be uploaded to the infrastructure before document registering of QRD. The `Questionnaire.identifier` can contain multiple identifiers but only the identifier for QFDD is allowed to have an `Identifier.system` starting with prefix `urn:oid:`
DocumentReference (soft reference from `Questionnaire.identifier` )	QFDD	`DocumentReference.masterIdentifier` shall contain the QFDD document id (matched in the Questionnaire `Questionnaire.identifier`). `DocumentReference.status` shall be `current`. `DocumentReference.type` must be Coding for QFDD type: `system` = `http://loinc.org` and `value` = `74468-0`). `DocumentReference.content.attachment.data` shall contain the QFDD xml content.

Transformation Details

CDA Header Transformation Details

It is described in the following table how logical parts in the transformation map to the header part of the CDA document. The CDA header part is common for all the Danish profiles with a few variations. Certain elements of the mapping is specific to the document type (marked as <specific to document type>). The details for these elements are specified in the sections on transformation of specific document types below.

Source (typically FHIR Resource)	Logical Part in Transformation	CDA Document	Details

Source (typically FHIR Resource)	Logical Part in Transformation	CDA Document	Details
Random UUID and details from the Infrastructure’s NamingSystem	Document id	/ClinicalDocument/id	Document identifier `value` = randomUUID system =`urn:oid:` + OID value from `NamingSystem.uniqueId.value` (where `uniqueId.type` is `oid`) from eHealthIdentifier `assigner` = the value of `NamingSystem.publisher` in eHealthIdentifier
<specific to document type>	Document title	/ClinicalDocument/title
System time at time of transformation	Time of document creation	/ClinicalDocument/effectiveTime
<specific to document type>	DocumentationOf (CDA Header)	/ClinicalDocument/documentationOf[0, 1, …]	Code(s) and datetime
`Composition.subject` referencing a Patient	Patient identification	/ClinicalDocument/recordTarget/patientRole	CPR-number (identification), name (given & family), gender, birth date, telecom
<specific to document type>	Author, Author Individual	/ClinicalDocument/author/assignedAuthor/assignedPerson	Name (given & family), prefix
`Composition.authorOrganization`	Author, Author Organization	/ClinicalDocument/author/assignedAuthor/id /ClinicalDocument/author/assignedAuthor/addr /ClinicalDocument/author/assignedAuthor/telecom /ClinicalDocument/author/assignedAuthor/representedOrganization/name	If `QuestionnaireResponse.source` is a patient, the author is patient and id will be CPR number. If `QuestionnaireResponse.source` is a practitioner , the author is practitioner and id will be a SOR organization.
`Composition.custodian`	Custodian Organization	/ClinicalDocument/custodian/assignedCustodian/representedCustodianOrganization
<specific to document type>	Legal Authenticator	/ClinicalDocument/legalAuthenticator	(Not generally used but depends on document type)
n/a	Information Recipient	/ClinicalDocument/informationRecipientOptional	Not used
n/a	Authenticator	/ClinicalDocument/authenticator	Not used
n/a	Optional Participant	/ClinicalDocument/participantOptional	Not used
n/a	Optional In Fulfillment Of	/ClinicalDocument/inFulfillmentOfOptional	Not used

PHMR Transformation Details

The PHMR transformation entails transformation of the CDA Header (see above) as well as PHMR-specific parts described below.

Source (typically FHIR Resource)	Logical Part in Transformation	CDA Document	Details

Source (typically FHIR Resource)	Logical Part in Transformation	CDA Document	Details
`Patient.identifier`	Document title	/ClinicalDocument/title	“Hjemmemonitorering for “ concatenated with Danish CPR, that is, `Patient.identifier.value` (where `system` is `urn:oid:1.2.208.176.1.2`)
`Observation.effective[x]`	DocumentationOf (CDA Header)	/ClinicalDocument/documentationOf[0, 1, …]	One DocumentationOf entry for time: effectiveTime = (`Observation.effective[x]` or widest span of multiple Observations `Observation.effective[x]`)
`Observation.code`			One DocumentationOf for each Observation.code
`Observation.component.code`			One DocumentationOf for each Observation.component.code
`composition.author`	Author, Author Individual	/ClinicalDocument/author/assignedAuthor/assignedPerson	Name (given & family), prefix
`Composition.attester.party` referencing an Organization	Legal Authenticator	/ClinicalDocument/legalAuthenticator

The following table details how logical parts in the transformation map to specific areas of the body part of a PHMR document.

Source (typically FHIR Resource)	Logical Part in Transformation	CDA Document	Details

Source (typically FHIR Resource)	Logical Part in Transformation	CDA Document	Details
n/a	Observation(s) Section - Results	/ClinicalDocument/component/structuredBody/component[2]/section (title=Results)	Grouping of zero, one or more Observations/Observation components
Observation	Per Observation (or Observation and Observation.component)	/ClinicalDocument/component/structuredBody/component[2]/section/entry/organizer/component/observation/
`Observation.identifier` (if an `Observation.identifier` has a system resolvable to OID type)	Measurement id	/ClinicalDocument/component/structuredBody/component[2]/section/entry/organizer/component/ovservation/id	id@extension is set to `Observation.identifier.value`. id@root is set to OID value resolved from `Observation.identifier.system`. Resolving as OID type system is either (in order): `Observation.identifier.system` prefixed with `urn:oid:` `Observation.identifier.system` can be matched to FHIR NamingSystem (in terminology service) which is has `NamingSystem.uniqueId.value` where `uniqueId.type` is `oid`
A random UUID (`Observation.identifier` has no system resolvable to OID type)	Measurement id		id@extension is set to random UUID id@root is set to `"1.2.208.176.7.200.1"` (which is OID type in )
`Observation.effective[x]`	Measurement time	/ClinicalDocument/component/structuredBody/component[2]/section/entry/organizer/effectiveTime	Start date of observation. If `Observation.effective` is a Period, the `Period.start` value is used if present, otherwise it is set to the `Period.end`. If `Observation.effective` is a DateTime or InstantType the value is used.
`Observation.code`	Measurement type	/ClinicalDocument/component/structuredBody/component[2]/section/entry/organizer/component/observation/code	SNOMED CT system with value set to nullFlavor.
`Observation.code`	Measurement type	/ClinicalDocument/component/structuredBody/component[2]/section/entry/organizer/component/observation/code/translation
`Observation.valueQuantity`	Measured value, unit	/ClinicalDocument/component/structuredBody/component[2]/section/entry/organizer/component/observation/value	Value and unit in percent are converted to unitless decimal (fraction).
`Observation.performer`	Measurement Method and Measured By (MethodCode)	/ClinicalDocument/component/structuredBody/component[2]/section/entry/organizer/component/observation/methodCode	The details for deciding the two method codes can be found in the table below.
`Observation.quality`	Measurement Method and Measured By (MethodCode)
`Observation.referenceRange`	Reference Range	/ClinicalDocument/component/structuredBody/component[2]/section/entry/organizer/component/observation/referenceRange	FHIR ranges are inverted to PHMR representation. Only `Observation.referenceRange.type` "GAL" and "RAL" are transformed. Other `Observation.referenceRange.type` are ignored as these are not supported in PHMR.
n/a	Observation(s) Section - Vital Signs	/ClinicalDocument/component/structuredBody/component[x]/section (title=Vital Signs)	Grouping of zero, one or more Observations/Observation components. Not used. Empty section created as specified in PHMR profile.
n/a	Medical Equipment Section	/ClinicalDocument/component/structuredBody/component[3]/section (title=Medical Equipment)	Grouping of one or more Device details
Device	Per Device in use	/ClinicalDocument/component/structuredBody/component[3]/section/entry/organizer
`Device.serialNumber` `Device.lotNumber`	Device identifier	/ClinicalDocument/component/structuredBody/component[3]/section/entry/organizer/participant/participantRole/id	If a serial number or lot number is present on the Device, the id is set to the number with assigningAuthority being the the number type and the root: “1.2.208.184“
the determined device type code (see below	Device identifier		When no `Device.serialNumber` or `Device.lotNumber` is present, the determined device type code is used, with assigningAuthority: "MedCom" and root: "1.2.208.184".
`Device.type` `Device.manufacturer` `Device.deviceName` `Device.modelNumber` `Device.version.value`	Device type code	/ClinicalDocument/component/structuredBody/component[3]/section/entry/organizer/participant/participantRole/playingDevice/code/translation	If a MedCom Instrument Code matching: `Device.type` `Device.manufacturer` `Device.deviceName` `Device.modelNumber` `Device.version.value` can be found, it is used. Otherwise set to the nullflavor NI
`Device.manufacturer` `Device.deviceName` `Device.modelNumber`	Manufacturer and Model Name	/ClinicalDocument/component/structuredBody/component[3]/section/entry/organizer/participant/participantRole/playingDevice/manufacturerModelName	Encoded string comprised of: Device manufacturer Device model and model number
`Device.serialNumber` `Device.lotNumber` `Device.version`	Software Name	/ClinicalDocument/component/structuredBody/component[3]/section/entry/organizer/participant/participantRole/playingDevice/softwareName	Encoded string, comprised of `device.version` and `device.serialNumber` or `device.lotNumber` depending on which is present.
n/a	External References		Not used

Determining MethodCodes

FHIR Observation.performer	FHIR Observation.quality	MethodCode 1 PerformerType	MethodCode 2 ProvisionMethod

FHIR Observation.performer	FHIR Observation.quality	MethodCode 1 PerformerType	MethodCode 2 ProvisionMethod
`Observation.performer` references Patient	`Observation.quality` contains `ehealth-quality` with: `qualityType` = UQ (Usage Quality) `qualityCode` = `http://ehealth.sundhed.dk/cs/usage-quality` \| `automatically-transferred`	POT (performed by citizen)	AUT (electronically)
`Observation.performer` references Practitioner with at least one `Practitioner.qualification` which has `qualification.identifier.system` = https://autregweb.sst.dk .		PNT (performed by healthcare professional)	AUT (electronically)
`Observation.performer` references Practitioner with no `Practitioner.qualification` or (if qualification present) none with `qualification.identifier.system` = https://autregweb.sst.dk .		PCG (performed by caregiver)	AUT (electronically)
`Observation.performer` references Patient	`Observation.quality` contains `ehealth-quality` with: `qualityType` = UQ (Usage Quality) `qualityCode` = `http://ehealth.sundhed.dk/cs/usage-quality` \| `entered-manually`	POT (performed by citizen)	TPD (typed in by citizen)
`Observation.performer` references Practitioner with at least one `Practitioner.qualification` which has `qualification.identifier.system` = https://autregweb.sst.dk .		PNT (performed by healthcare professional)	TPH (typed in by healthcare professional)
`Observation.performer` references Practitioner with no `Practitioner.qualification` or (if qualification present) none with `qualification.identifier.system` = https://autregweb.sst.dk .		PCG (performed by caregiver)	TPC (typed in by caregiver)

Transforming Reference Ranges

Reference ranges (aka measurement ranges) are supported as regular, sensible ranges in the eHealth Infrastructure. In the PHMR, they are expressed as alarm thresholds. Oddly, the PHMR uses a range construct to carry the lower and higher threshold values, respectively, in effect describing an inverted range where the alarm is not in effect. Furthermore, the PHMR can contain zero, one or two alarm thresholds per observation. As shown in the figure below, the measurement range(s) in a FHIR Observation are transformed to such alarm thresholds for the PHMR document.

There need not be both yellow and red type measurement ranges and they need not be symmetrical as in the figure above. There are, however, certain constraints on which measurement ranges are supported due to the representation as alarm thresholds:

at most two yellow and two red measurement ranges are supported and they cannot be interleaved (for instance red, yellow, red, yellow)
the outermost measurement range cannot have both high and low value (because the alarm threshold is open-ended)
the outermost measurement range cannot be yellow if it is preceded by a red measurement range

In the example above, measurement ranges are overlapping (for instance yellow high value is equal to red low value) which the Clinical Administration Application prevents by requiring non-overlapping intervals. In reality, the measurement ranges will be non-overlapping by use of exclusiveness. This is accounted for in the transformation to alarm threshold through use of the PHMR inclusive=false | true construct.

Error situations

The transformation terminates in the error situations given below.

Situation	Error message

Situation	Error message
`Observation.quality` is empty or contains no `ehealth-quality` with: `qualityType` = UQ (Usage Quality) `qualityCode` = `http://ehealth.sundhed.dk/cs/usage-quality \|` `automatically-transferred` or `http://ehealth.sundhed.dk/cs/usage-quality \|` `entered-manullay`	Method codes for performerType and provisionMethod for observation with id {observationId} could not be established
`Observation.performer` references ehealth-organization or ehealth-relatedperson.	Method codes for performerType and provisionMethod for observation with id {observationId} could not be established
`Observation.effective` is of type Timing. Valid types are: dateTime, Period and instant.	Invalid Observation.effective, expecting DateTime, Period or Instant
`Observation.value` is missing or is not of type Quantity.	Value should be Quantity type and not null
`Observation.referenceRange` component contains both low and high values.	Observation ranges should not have both High and Low set when transforming to PHRM, but High is: {high}, and Low is: {low}
`Observation.referenceRange` component value contains more than 7 decimals.	Value should have no more than 7 decimals, but is: {value}
`Patient.identifier` contains no CPR (Danish citizen identifier).	CPR is mandatory for patient but not present in fhir bundle
`Observation.note.author` is not of type Reference(Practitioner \| Patient \| RelatedPerson \| Organization) \| string.	Unknown author type: {authorType}
`Composition.author` is missing or is not of type Patient \| Practitioner.	Composition.author should either be a Patient or Practitioner
`Composition.authorOrganization` does not contain SOR identifier.	Composition.authorOrganization must contain SOR identifier
`Composition.attester` organization does not contain SOR identifier.	Composition.attester.party must contain SOR identifier
`Composition.custodian` organization does not contain SOR identifier.	Custodian organization must contain SOR identifier
`Composition.authorOrganization` is missing.	Composition.authorOrganization is mandatory for transformation
`Composition.custodian` is missing.	Custodian is mandatory for transformation
`Composition.identifier` is missing.	Identifier on composition is mandatory
`Composition.confidentiality` is missing.	Composition.confidentiality is mandatory
`Composition.subject` is not of type Patient.	Composition.subject should be a Patient
Narrative in Results section and/or Medical Equipment section cannot be generated due to unexpected issues.	Can't generate narrative for: medical equipment OR Can't generate narrative for: results

QRD Transformation Details

The QRD transformation entails transformation of the CDA Header (see above) as well as QRD-specific parts described below.

Matching between FHIR Questionnaire, FHIR QuestionnaireResponse and QFDD

Just like the FHIR QuestionnaireResponse must be structurally consistent with the FHIR Questionnaire, the QRD must be structurally consistent with the QFDD. It follows that transformation of a FHIR QuestionnaireResponse to a QRD implies that the FHIR Questionnaire must be an approximation of the QFDD.

The following are prerequisites for a FHIR Questionnaire (shortened Questionnaire and covering both the ehealth-questionnaire and ehealth-questionnaire-advanced profiles) to be an approximation of a QFDD:

At root level of the FHIR Questionnaire, the number of question groups (Questionnaire.item with item.type set to group) shall match the number of QFDD sections for all but QFDD copyright section.
- Rationale: Copyright is placed in Questionnaire.copyright.
For each QFDD section except Information Only sections, the number of FHIR Questionnaire subgroups (Questionnaire.item.item with item.type set to group) shall match the number of QFDD organizers inside the section.
- The Questionnaire.item.item.externalIdentifier (on a subgroup) shall match the QFDD organizer id.
For each QFDD question within an organizer there shall be a FHIR Questionnaire question item (Questionnaire.item.item.item)
- The Questionnaire.item.item.item.externalIdentifier shall match the QFDD question id.
- A QFDD question with associated text shall have the associated text represented as a separate FHIR Questionnaire question item (Questionnaire.item.item.item)
Calculation type Questionnaire.item at any level are allowed in the FHIR Questionnaire without counterpart in the QFDD
- Rationale: Calculations and formulas are not represented in QFDD.

Overall these prerequisites for approximation of QFDD ensures that the FHIR Questionnaire is structurally compatible with QFDD. In addition, groups, subgroups and questions must have the same ids and the same order. Also, the use of coded values for questions, answer options, and possibly subgroups must be identical.

The QFDD organizer/question id is matched to the corresponding item in a FHIR Questionnaire by item.item.item.extension.externalIdentifier. The Questionnaire.item.linkId is compared with QuestionnaireResponse.item.linkId (at any level, that is also for Questionnaire.item.item and .item.item.item) to locate the same item in the QuestionnaireResponse.

Validation

As part of the transformation from FHIR QuestionnaireResponse to QRD, validation of the QFDD approximation prerequisites is performed.

Information Only Section

Logical Part	QRD Document	Details

Logical Part	QRD Document	Details
Information Only Section	/ClinicalDocument/component/structuredBody/component/section	A root item on `Questionnaire.item` with `Questionnaire.item.type: "group"` A child item with type: `Questionnaire.item.type: "display"`
Title	…/component/section/title	From root item `Questionnaire.item.text` else QFDD section title (…/component/section/title)
Narrative	…/component/section/text	QFDD text (…/component/section/text)
Language	languageCode	`Questionnaire.language`

Questionnaire Response Section

Logical Part	QRD Document	Details

Logical Part	QRD Document	Details
Questionnaire Response Section	/ClinicalDocument/component/structuredBody/component/section	A root item on `Questionnaire.item` with `Questionnaire.item.type: "group"`
Title	…/component/section/title	From root item `Questionnaire.item.text` else QFDD section title (…/component/section/title)
Narrative	…/component/section/text	QFDD text (…/component/section/text) The narrative (QFDD text) from the QFDD section is updated with answers before being assigned to the QRD section text.
Language	languageCode	`Questionnaire.language`

Response Organizer

Logical Part	QRD Document	Details

Logical Part

QRD Document

Details

Response Organizer

/ClinicalDocument/component/structuredBody/component/section/entry/organizer

An item of type item.type: "group" inside a root item of type Questionnaire.item.type: "group".

Only items of type item.type: "group" are allowed at the level below the root item.

OBS: Items with calculated expression are allowed but is ignored during transformation.

Id

…/section/entry/organizer/id

QFDD id (…/section/entry/organizer/id).

Validating if item(item.extension.externalIdentifier) inside subgroup matches QFDD organizer id.

Code

…/section/entry/organizer/code

Uses code from Questionnaire item item.code

Code: item.code.code

CodeSystem: ifitem.code.system has prefix “urn:oid:” then item.code.system without prefix. Else lookup in Questionnaire Terminology.

CodeSystemName: is fetched from CodeSystem in Questionnaire Terminology. Value is taken in the following order: codeSystem.title, codeSystem.name, codeSystem.url or “Unknown“.

Display: item.text or else item.code.display

OriginalText: Question text (item.text) or, if not present, (item.code.display)

Numeric Response Pattern Observation

Logical Part	QRD Document	Details

Logical Part	QRD Document	Details
Numeric Response Pattern Observation	/ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation	An item inside a subgroup Root item with `Questionnaire.item.type: "group"` (QRD section) Sub group item with `item.type: "group"` (QRD organizer) Question item Numeric Response if `item.type` is either Integer, Decimal or DateTime If `item.extension` does not contain http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl with value ‘slider’
Id	…/observation/id	Uses Id from QFFD question Validating if Questionnaire item(`item.extension.externalIdentifier`) matches QFDD question id
Code	…/observation/code	Uses code from Questionnaire item `item.code` Code: `item.code.code` CodeSystem: if`item.code.system` has prefix “urn:oid:” then `item.code.system` without prefix. Else lookup in Questionnaire Terminology. CodeSystemName: is fetched from CodeSystem in Questionnaire Terminology. Value is taken in the following order: codeSystem.title, codeSystem.name, codeSystem.url or “Unknown“. Display: `item.text` or else `item.code.display` OriginalText: Question text (`item.text`) or, if not present, (`item.code.display`)
Answer	…/observation/value	Value: `QuestionnaireResponse.item.answer` For `Questionnaire.item.type` = `integer`, the question answer value is from `QuestionnaireResponse.item.answer.valueInteger`. For `Questionnaire.item.type` = `decimal`, the question answer value is from `QuestionnaireResponse.item.answer.valueDecimal`. For `Questionnaire.item.type` = `datetime`, the question answer value is from `QuestionnaireResponse.item.answer.valueDateTime` (formatted as YYYYMMDDHHmmssZ). QRD Type: `Questionnaire.item.type` equal Integer then 'INT' `Questionnaire.item.type` equal Decimal then ‘REAL’ `Questionnaire.item.type` equal DateTime then 'TS'
Help text Image	…/observation/entryRelationship	Is added if Questionnaire item has one or more extensions: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaire-helpText http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaire-image
External reference	…/observation/reference	The QFDD unique id. From id element and the property 'extension'
Range	…/observation/referenceRange	If `Questionnaire.item` has the following extension the referenceRange is assigned http://hl7.org/fhir/StructureDefinition/minValue http://hl7.org/fhir/StructureDefinition/maxValue

Analog Slider Response Pattern Observation

Logical Part	QRD Document	Details

Logical Part	QRD Document	Details
Analog Slider Response Pattern Observation	/ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation	An item inside a subgroup Root item with type: “Group” (QRD section) Sub group item with type: “Group” (QRD organizer) Question item Analog Slider Response if `item.type` is either Integer or Decimal If `item.extension` contain http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl with value ‘slider’ if `item.extension` contains http://hl7.org/fhir/StructureDefinition/minValue http://hl7.org/fhir/StructureDefinition/maxValue an either http://hl7.org/fhir/StructureDefinition/questionnaire-sliderStepValue (integer) http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaire-sliderStepValueDecimal (Decimal) Properties: id, code, value, entryRelationship and reference is the same configuration as for numeric Response
Id	…/observation/id	Uses Id from QFFD question Validating if Questionnaire item(`item.extension.externalIdentifier`) matches QFDD question id
Code	…/observation/code	Uses code from Questionnaire item `item.code` Code: `item.code.code` CodeSystem: if`item.code.system` has prefix “urn:oid:” then `item.code.system` without prefix. Else lookup in Questionnaire Terminology. CodeSystemName: is fetched from CodeSystem in Questionnaire Terminology. Value is taken in the following order: codeSystem.title, codeSystem.name, codeSystem.url or “Unknown“. Display: `item.text` or else `item.code.display` OriginalText: Question text (`item.text`) or, if not present, (`item.code.display`)
Answer	…/observation/value	Value: `QuestionnaireResponse.item.answer` . For `Questionnaire.item.type` = `integer`, the question answer value is from `QuestionnaireResponse.item.answer.valueInteger`. For `Questionnaire.item.type` = `decimal`, the question answer value is from `QuestionnaireResponse.item.answer.valueDecimal`. Type: `Questionnaire.item.type` equal Integer then 'INT' `Questionnaire.item.type` equal Decimal then ‘REAL’
Help text Image	…/observation/entryRelationship	Is added if Questionnaire item has one or more extensions: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaire-helpText http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaire-image
External reference	…/observation/reference	The QFDD unique id. From id element and the property 'extension'
Range	…/referenceRange/observationRange/	Denominator: `item.extension` http://hl7.org/fhir/StructureDefinition/maxValue Head: `item.extension` http://hl7.org/fhir/StructureDefinition/minValue Increment: `item.extension`either value from questionnaire-sliderStepValue or ehealth-questionnaire-sliderStepValueDecimal

Text Response Pattern Observation

Logical Part	QRD Document	Details

Logical Part	QRD Document	Details
Text Response Pattern Observation	/ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation	An item inside a subgroup Root item with type: “Group” (QRD section) Sub group item with type: “Group” (QRD organizer) Question item Test Response if `item.type` is either text, string or openchoice
Id	…/observation/id	Uses Id from QFFD question Validating if Questionnaire item(`item.extension.externalIdentifier`) matches QFDD question id
Code	…/observation/code	Uses code from Questionnaire item `item.code` Code: `item.code.code` CodeSystem: if`item.code.system` has prefix “urn:oid:” then `item.code.system` without prefix. Else lookup in Questionnaire Terminology. CodeSystemName: is fetched from CodeSystem in Questionnaire Terminology. Value is taken in the following order: codeSystem.title, codeSystem.name, codeSystem.url or “Unknown“. Display: `item.text` or else `item.code.display` OriginalText: Question text (`item.text`) or, if not present, (`item.code.display`)
Answer	…/observation/value	Value: `QuestionnaireResponse.item.answer` . For `Questionnaire.item.type` = `text`, `string` or `openchoice` , the question answer is a text string in QRD. Question answer text is from `QuestionnaireResponse.item.answer.valueString`. Type: ST
Help text Image	…/observation/entryRelationship	Is added if Questionnaire item has one or more extensions: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaire-helpText http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaire-image
External reference	…/observation/reference	Value from QFDD. From id element and the property 'extension'

Multiple Choice Response Pattern Observation

Logical Part	QRD Document	Details

Logical Part	QRD Document	Details
Multiple Choice Response Pattern Observation	/ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation	An item inside a subgroup Root item with type: “Group” (QRD section) Sub group item with type: “Group” (QRD organizer) Question item Multiple Choice Response if `item.type` is choice `item.extension` has no extension containing http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl with value ‘slider’
Id	…/observation/id	Uses Id from QFFD question Validating if Questionnaire item(`item.extension.externalIdentifier`) matches QFDD question id
Code	…/observation/code	Uses code from Questionnaire item `item.code` Code: `item.code.code` CodeSystem: if`item.code.system` has prefix “urn:oid:” then `item.code.system` without prefix. Else lookup in Questionnaire Terminology. CodeSystemName: is fetched from CodeSystem in Questionnaire Terminology. Value is taken in the following order: codeSystem.title, codeSystem.name, codeSystem.url or “Unknown“. Display: `item.text` or else `item.code.display` OriginalText: Question text (`item.text`) or, if not present, (`item.code.display`)
Answer	…/observation/value	Value: from `QuestionnaireResponse.item.answer` . For `Questionnaire.item.type` = `choice` , the question answer(s) is one or more coded elements in QRD. Question answer code is from `QuestionnaireResponse.item.answer.valueCoding`. Code: `answer.code` CodeSystem: if `answer.system` has prefix “urn:oid:” then `item.code.system` without prefix. Else lookup in Questionnaire Terminology. CodeSystemName: is fetched from CodeSystem in Questionnaire Terminology. Value is taken in the following order: codeSystem.title, codeSystem.name, codeSystem.url or “Unknown“. Display: `answer.display`
Help text Image Associated text question	…/observation/entryRelationship	Is added if Questionnaire item has one or more extensions: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaire-helpText http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaire-image And if QFDD has associated text question and preconditions are fulfilled. Structure for associated text question in FHIR Questionnaire: Root item with type: “Group” (QRD section) Sub group item with type: “Group” (QRD organizer) Question item with type: “choice“ Associated text question item (The item must be right after the question) OBS: Supported precondition for Associated text question: Only one precondition element The precondition is only based on answers from the related multiple choice (no reference to other questions) Supported groupers inside the one preconditon element AllTrue AllFalse AtLeastOneTrue AtLeaseOneFalse OnlyOneTrue OnlyOneFalse
External reference	…/observation/reference	The QFDD unique id. From id element and the property 'extension'
Range	…/observation/referenceRange	If `Questionnaire.item` has the following extension the referenceRange is assigned http://hl7.org/fhir/StructureDefinition/minValue http://hl7.org/fhir/StructureDefinition/maxValue

Discrete Slider Response Pattern Observation

Logical Part	QRD Document	Details

Logical Part	QRD Document	Details
Discrete Slider Response Pattern Observation	/ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation	An item inside a subgroup Root item with type: “Group” (QRD section) Sub group item with type: “Group” (QRD organizer) Question item Multiple Choice Response if `item.type` is choice `item.extension` has the following extensions: http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl with value: ‘slider’ http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs with value: 1
Id	…/observation/id	Uses Id from QFFD question Validating if Questionnaire item(`item.extension.externalIdentifier`) matches QFDD question id
Code	…/observation/code	Uses code from Questionnaire item `item.code`. Code: `item.code.code` CodeSystem: if`item.code.system` has prefix “urn:oid:” then `item.code.system` without prefix. Else lookup in Questionnaire Terminology. CodeSystemName: is fetched from CodeSystem in Questionnaire Terminology. Value is taken in the following order: codeSystem.title, codeSystem.name, codeSystem.url or “Unknown“. Display: `item.text` or else `item.code.display` OriginalText: Question text (`item.text`) or, if not present, (`item.code.display`)
Value	…/observation/value	Value: from `QuestionnaireResponse.item.answer` . For `Questionnaire.item.type` = `choice` , the question answer is one coded element in QRD. Question answer code is from `QuestionnaireResponse.item.answer.valueCoding`. Code: `Coding.code` CodeSystem: if `Coding.system` has prefix “urn:oid:” then `Coding.system` without prefix. Else lookup in Questionnaire Terminology. CodeSystemName: is fetched from CodeSystem in Questionnaire Terminology. Value is taken in the following order: codeSystem.title, codeSystem.name, codeSystem.url or “Unknown“. Display: `Coding.display`
Max occurrence Min occurrence Help text Image	…/observation/entryRelationship	Low: http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs High: http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs always 1 (1 only allowed value for Discrete Slider type) Is added if Questionnaire item has one or more extensions: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaire-helpText http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaire-image
QFDD reference	…/observation/reference	The QFDD unique id. From id element and the property 'extension'

Copyright Section

Logical Part	QRD Document	Details

Logical Part	QRD Document	Details
Copyright Section	/ClinicalDocument/component/structuredBody/component/section	Copyright section is copied directly from the QFDD

Supported types

FHIR Questionnaire.item.type	QRD Response Pattern Observation

FHIR Questionnaire.item.type	QRD Response Pattern Observation
text, string, openchoice	Text Response Pattern Observation
choice	Multiple Choice Response Pattern Observation Discrete Slider Response Pattern Observation (when `Questionnaire.item.extension.itemControl` has value 'slider' and `Questionnaire.item.maxOccurs` = 1)
decimal, integer	Numeric Response Pattern Observation Analog Slider Response Pattern Observation (when `Questionnaire.item.extension.itemControl` has value 'slider' )
datetime	Numeric Response Pattern Observation

QFDD Transformation Details

The QFDD transformation entails transformation of the CDA Header (see above) as well as QFDD-specific parts described below.

Overall and except for certain details described below, the structure of the Questionnaire must match the structure of the QFDD.

This means that the structure rules below must be adhere to and that information sections/groups and questions must be in the same order.

QFDD Element	FHIR Questionnaire	Comment

QFDD Element

FHIR Questionnaire

Comment

Information Only Section

A Questionnaire.item at root level with Questionnaire.item.type ="group"

A single child item Questionnaire.item.item with .type = "display"

Question Section (with one or more Question Organizer)

A Questionnaire.item at root level with Questionnaire.item.type ="group"

For each QFDD Question Organizer:

A single child item Questionnaire.item.item with .type = "group"

For each question in the group/QFDD Question Organizer:

A single child item Questionnaire.item.item.item with .type = subtype of "question"

Not transformed as algorithms and expressions are not supported in QFDD.

A Questionnaire.item at any level with .type = "decimal" and .readOnly = "true"

A Calculated expression within the questionnaire, see

eHealth Infrastructure Wiki

Performing Document Query/Retrieve and Transforming to/from Documents

Performing Document Query and Document Retrieve

Provided Transformations between FHIR resources and Danish CDA Profiles

Preparing Transformations by Assembling Required FHIR Resources

Assembling FHIR Resources for Transformation to PHMR

Assembling FHIR Resources for Transformation to QRD

Transformation Details

CDA Header Transformation Details

PHMR Transformation Details

Determining MethodCodes

Transforming Reference Ranges

Error situations

QRD Transformation Details

Matching between FHIR Questionnaire, FHIR QuestionnaireResponse and QFDD

Validation

Information Only Section

Questionnaire Response Section

Response Organizer

Numeric Response Pattern Observation

Analog Slider Response Pattern Observation

Text Response Pattern Observation

Multiple Choice Response Pattern Observation

Discrete Slider Response Pattern Observation

Copyright Section

Supported types

QFDD Transformation Details