Beskrivning av hur lösningen möter EDHS krav:
Referens till vart ex tjänstekontrakt och attribut/fält
Textuell beskrivning hur
Bedömning:
Fyll i med någon av följande "statuskoder".
OK Informationen stämmer väl överens med EHDS ( struktur, kodat eller fritext enligt krav)
KODAD EJ ENLIGT EHDS Informationens struktur stämmer väl överens med EHDS OCH är kodad, men kodsystem stämmer EJ överens med EHDS (ange kodsystem)
STRUKTUR ENLIGT EHDS Informationens struktur stämmer väl överens med EHDS (men är fritext, EJ kodad enligt krav)
STRUKTUR EJ EHDS Informationen finns strukturerad, men strukturen stämmer EJ överens med EHDS (gäller kodad och fritext)
EJ STRUKTURERAD Informationen är inte strukturerad (men finns som fritext)
SAKNAS Informationen saknas helt
Täckningsgrad:
Vilken
Kvalité på informationen:
eHN Guidelines:
| Data | Description | Preferred Code Systems | Arbetsgruppens ("Svensk") tolkning av informationselementet | Utvärderingsparametrar | Inera | E-hälsomyndigheten | Socialstyrelsen | Systemleverantörer | Regional hälso- och sjukvård | Kommunal hälso- och sjukvård |
| * ** A.2 Patient summary body data elements | ||||||||||
| A.2.3 Medical problems | Ur uppdrag: SKR:s och Ineras pågående jämförelser mellan NPÖ och EHDS-kraven för patientöversikt för aktuella diagnoser | Motsvarar innehållet i tjänstekontraktet GetDiagnosis | ||||||||
| A.2.3.1.1 Problem / diagnosis description | Health conditions affecting the health of the patient and are important to be known for a health professional during a health encounter. | ICD-10* SNOMED CT GPS Orphacode if rare disease is diagnosed | Beskrivning av hur lösningen möter EDHS krav | Motsvaras av diagnosis/ diagnosisBody/ diagnosisCode | ||||||
| Bedömning | Saknar krav på terminologibindning. Är i praktiken en ICD-10-kod för besökets diagnos. Måsta anges som huvuddiagnos eller bidiagnos, samt kan flaggas som kronisk. Fritext är tillåtet. | |||||||||
| Täckningsgrad | ||||||||||
| Kvalité på informationen | ||||||||||
| A.2.3.1.2 Onset date | Date of problem onset | ISO 8601 | Beskrivning av hur lösningen möter EDHS krav | Saknas, enda tidpunkten som utbyts är tidpunkten när bedömningen gjordes. | ||||||
| Bedömning | ||||||||||
| Täckningsgrad | ||||||||||
| Kvalité på informationen | ||||||||||
| A.2.3.1.3 Diagnosis assertion status | Assertion about the certainty associated with a diagnosis. Diagnostic and/or clinical evidence of condition. | HL7 | Beskrivning av hur lösningen möter EDHS krav | Namn och/eller HSAid för den som signerat. diagnosis/diagnosisHeader/legalAuthenticator Referens till underlag i form av bedömning eller testresultat kan ej anges. | ||||||
| Bedömning | ||||||||||
| Täckningsgrad | ||||||||||
| Kvalité på informationen | ||||||||||
* In a foreseeable future, the suggested preferred vocabularies might be superseded or
complemented, as mentioned in Guidelines Article 11(2).
** The Preferred code system(s) has been selected based on adequacy to convey the
information using the methodology of the Subgroup on Semantics. When more alternative
international code systems are available, all are listed when it is assumed to be unlikely that
agreement can be reached short term. Mapping between code systems could be proposed for
specific use cases.
Xt-EHR Logical model:
| Short | Definition | Min | Max | Type(s) | Binding Strength | Binding Description | ||||
| B.1.3.2 - Current problems section | Current problems section | 0 | 1 | Base | ||||||
| B.1.3.2.1 - Subsection narative | Narative content of the subsection. | 0 | 1 | string | ||||||
| B.1.3.2.2 - Current problems | Health conditions affecting the health of the patient and are important to be known for a health professional during a health encounter. | 1 | * | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition |
| Short | Definition | Min | Max | Type(s) | Binding Strength | Binding Description | ||||
| Condition model | C.15 - EHDS refined base model for A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. | 0 | * | |||||||
| C.15.1 - Identifier | Condition identifier | 0 | * | Identifier | ||||||
| C.15.2 - Description | Condition specification in narrative form | 0 | 1 | Narrative | ||||||
| C.15.3 - Code | Code identifying the condition, problem or diagnosis | 0 | 1 | CodeableConcept | preferred | ICD-10*, SNOMED CT, Orphacode if rare disease is diagnosed | ||||
| C.15.4 - Onset date | Onset date of a problem/condition | 0 | 1 | dateTime | ||||||
| C.15.5 - End date | The date or estimated date that the condition resolved or went into remission. | 0 | 1 | dateTime | ||||||
| C.15.6 - Category | Category or categories of the problem. | 0 | * | CodeableConcept | ||||||
| C.15.7 - Clinical status | Status of the condition/problem (active, resolved, inactive, ...) | 0 | 1 | CodeableConcept | preferred | HL7 Condtion-clinical | ||||
| C.15.8 - Resolution circumstances | Describes the reason for which the status of the problem changed from current to inactive (e.g. surgical procedure, medical treatment, etc.). This field includes "free text" if the resolution circumstances are not already included in other fields such as surgical procedure, medical device, etc., e.g. hepatic cystectomy (this will be the resolution circumstances for the problem "hepatic cyst" and will be included in surgical procedures). | 0 | * | CodeableReference(Resource) | ||||||
| C.15.9 - Severity | A subjective assessment of the severity of the condition as evaluated by the clinician. | 0 | 1 | CodeableConcept | preferred | HL7 Condtion-severity | ||||
| C.15.10 - Anatomic location | The anatomical location including laterality where this condition manifests itself. | 0 | * | CodeableConcept | preferred | SNOMED CT | ||||
| C.15.11 - Stage | Stage/grade usually assessed formally using a specific staging/grading system. Multiple assessment systems could be used. | 0 | * | CodeableConcept | preferred | e.g. TNM, ICD-O-3, Bi-Rads, Li-Rads, … | ||||
| C.15.12 - Subject | Indicates the patient or group who the condition record is associated with. | 1 | 1 | Reference(https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSGroup) | ||||||
| C.15.13 - Participant | Who or what participated in the activities related to the condition and how they were involved. | 0 | * | Base | ||||||
| C.15.13.1 - Function | Type of participant involvement. | 0 | 1 | CodeableConcept | preferred | To be specified | ||||
| C.15.13.2 - Actor | Identify the Health Professional who may be specifically related to the condition, e.g., as a preferred contact. | 1 | 1 | Reference(https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional) | ||||||
| C.15.14 - External Resourcerelated with | Identify the External Resource which may be specifically relatedto the problem, for example a link between a rare disease problemand the corresponding guidelines. | 0 | * | uri | ||||||
| C.15.15 - Diagnosis assertion status | Assertion about the certainty associated with a diagnosis. Diagnostic and/or clinical evidence of condition. | 0 | 1 | CodeableConcept | preferred | HL7 Condition-ver-status |