View raw Markdown
type: resourceresource: DetectedIssue

DetectedIssue

Introduction

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:

This resource represents a specific instance of a potential issue for a particular patient. It is not intended to represent general patient-independent 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 solid oral dose forms" or "No MRIs - metallic tattoos". These guidelines can be captured using the AllergyIntolerance, AdverseEvent and/or Flag resources. 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.

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, 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.

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" 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" 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.

Notes

Linking to Detected Issues

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

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.

Open Issues

StructureDefinition

Elements (Simplified)

Mappings

Resource Packs

list-DetectedIssue-packs.xml

<?xml version="1.0" encoding="UTF-8"?>

<List xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../publish/List.xsd">
  <id value="DetectedIssue-packs"/>
  <status value="current"/>
  <mode value="working"/>
</List>

Search Parameters

Full Search Parameters

Examples

Full Examples

Mapping Exceptions

detectedissue-event-mapping-exceptions.xml

Divergent Elements

Unmapped Elements

detectedissue-fivews-mapping-exceptions.xml

Unmapped Elements