KISIM Medical Report IG - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
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| Official URL: http://fhir.kisimdocs.ch/ig/KisimMedicalReport/ImplementationGuide/hl7.fhir.ch.kisimmedicalreport | Version: 0.1.0 | |||
| Draft as of 2025-04-24 | Computable Name: KisimMedicalReportIg | |||
Cistec Medical Report
The following Implementation Guide (IG) describes the interaction with the Cistec AG EHR to create medical reports.
The following implementation guide is a draft. Implementers should be aware of that. It is quite possible that breaking changes to the current specification might be introduced in future releases.
Vocabulary
| Name | Description |
|---|---|
| CISTEC | The publisher of this IG |
| KISIM | The clinical information system from CISTEC. Also used when referenced to the server |
| "Client" or "client system" | The implementer of this IG |
| "Report" or "Medical Report" | Coupled data representing the documentation of a current treatment, the current anamnesis of a patient or a similar dataset. |
| compoundId | An id referencing to a set of Questionnaire resources stored on the server. They can be extracted with the `$aggregate` or `$medical-report` operation |
| K5/K6 | Type of underlining medical report implementation in KISIM. See also K5/K6 |
What is a medical report?
A medical report is a generic dataset inside KISIM. It can represent anything from the anamnesis of a patient, a letter of care transition, the documentation of a current treatment or anything else loosely related.
The following list is a set of examples representing a report inside KISIM.
For simplicity and since KISIM is mostly in german, the german names of the reports are used:
- Eintrittsbericht: A report containing all the relevant data at the time the patient entered the care facility. It contains data such as anamnesis, general state of health, diagnosis, pregnancy information and any other information which is deemed relevant for the treatment of the patient.
- Austrittsbericht: A report containing all the relevant data at the time the patient leavers the care facility. It contains the information related to the treatment of the patient. What was the problem, what has been done, where was the patient sent after the treatment and why.
- Konsilium: A report which is written in case the treatment of the patient needed to be consolidated with different healthcare specialists.
It becomes clear that a report is a wrapper around a set of information. This information might be loosely coupled, but it is not inherently clear, what exactly a medical report contains. There are many different implementations of such reports and the corresponding data structure is often similar but not the same. This poses a problem for client systems which want or need to write a KISIM report.
How to submit a medical report
To submit a report, a client system must perform a few tasks. Initially the client system is invoked with a set of parameters. Depending on the use case those parameters might differ a little.
After the client system received the parameters, it then can perform the following actions with said parameters:
- Request report structure
- Fill report structure
- Submit filled report structure
FHIR representation
The following chapter shows, how the previously described and highly simplified calls are modeled in FHIR.
Report structure
The report structures are implemented as Questionnaire resources. Questionnaires represent a set of questions intended to solicit information from patients.
When a system requests the report structures from KISIM it will receive one or more Questionnaire resources.
To fill the questionnaires, a client system has to implement the SDC Form Filler profile and return the Questionnaires with a corresponding set of one or more [QuestionnaireResponse])https://hl7.org/fhir/R4/questionnaireresponse.html) resources.
Submit data as document
To submit data to KISIM, a Bundle of type document is used.
The bundle must contain the following resources:
- Composition like every document
- Encounter
- Questionnaire
- QuestionnaireResponse
- Practitioner the author of the document
Additional information can be sent:
For a detailed description of the bundle, see Document Bundle
How to interact with KISIM
The following chapter illustrates, how a client system can interact with KISIM to submit a medical report.
Client system invocation
At first, the client system needs to be invoked from somewhere with the initial information. The implementation of such a call is described here.
Get resources to build the document
To get the resources from the server, there are two different ways. If a client system wants to build
the complete document by itself and only needs the Questionnaire resources, there is the Questionnaire/$aggregate operation.
If a client system wants KISIM to produce all the necessary resources except for the QuestionnaireResponses and DocumentReferences
there is the Bundle/$medical-report operation.
$aggregate operation
To get the questionnaires from the FHIR Server, a client system needs either:
- a questionnaireId
- a compoundId
The client system then needs to call the $aggregate operation
Examples on how to read Questionnaires from KISIM can be found here
$medical-report operation
As with the $aggregate operation, the $medical-report operation allows a client system to receive a set of
resources from the KISIM FHIR Server. Those resources are the ones needed to then build the Document-Bundle which must
be submitted to the FHIR-Server.
The $medical-report operation is described here.
Fill report structure
Each questionnaire received by the server can be answered. A corresponding QuestionnaireResponse needs to result out of such an operation. How a client answers the Questionnaire is up to the individual client system.
Submit filled report structure
To submit the data, the previously mentioned document Bundle is used.
All the resources received by the server by either the $aggregate or the $medical-report operation need
to be added to a Document Bundle. In addition, the QuestionnaireResponse resources from the client system and
additional information such as a transcript or an audio file can be submitted by DocumentReference resources.
The complete process of building an example bundle and how to submit it can be found here