Table 1.
Description and structure of the six core FHIR-templates of the EHR4CR mediation model.
| Template (nb. of data elements) | Template scope | Specialized template scope | Data element | Terminlogy binding Value set | Nb. of concept s |
|---|---|---|---|---|---|
| Patient (n=4) | A Patient is a uniquely identified person. Clinical statements attached to this Patient may be recorded within the source systems. | administrativeGenderCode | SCT gender types | 4 | |
| birthTime | |||||
| deceasedInd | |||||
| deceasedTime | |||||
| Encounter(n=4) | An Encounter occurrence correspond to a period of time a Patient continuously receives medical services from one or more providers at a care site in a given setting within the health care system. | code | SCT encounter types | 6 | |
| dischargeDispositionCode | |||||
| effectiveTime | |||||
| lengthOfStayQuantity | |||||
| Condition (n=2) | Conditions state the presence of a clinical disease, sign or symptom, etc. | nonDiseaseCondition:correspond to symptoms (observed by the patient) or signs (observed by a care provider). | category | SCT condition types | 4 |
| code | Subset of SCT findings | 16 | |||
| diseaseCondition: are inferred from medical claims data, textual clinical document, collected via forms (e.g. from a problem list), etc. | category | SCT diagnostic types | 25 | ||
| code | diseases(ICD10+subset of SCT diseases) | 12500 | |||
| clinicalObservation(n=2) | A (numerical or categorical) Observation is a sign or a symptom or the result of any procedure which is either observed by a Provider or reported by the Patient. | clinicalObservation:records of measurements performed by a clinician at bed side (including scores, grades, stages, etc.) | name | subset of SCT observable entities | 26 |
| value | value sets specific to each categorical observable entity | 95 | |||
| vitalSignObservation:refer to blood pressure, body temperature, pulse rate and respiratory rate. | name | subset of SCT vital signs | 5 | ||
| value | |||||
| laboratoryObservation: refer to laboratory tests. | name | subset of LOINC codes (Top 2000) | 2000 | ||
| value | value sets specific to each categorical observable entity | >500 | |||
| anatomicPathologyO bservation: records of measurements performed by a pathologist analyzing tissues/cells with a microscope (including scores, grades, stages, etc). | name | subset of LOINC codes (Top 80) | 80 | ||
| value | value sets specific to each categorical observable entity (e.g. ICD-O, TNM, etc) | >500 | |||
| Procedure(n=1) | A Procedure occurrence correspond to the record of an activity or process ordered by, or carried out by, a healthcare provider on the patient with a diagnostic or therapeutic purpose. Procedures are inferred from medical claims include, computerized orders in EHRs, etc. | code | subset of SCT procedures | 57 | |
| Medication Statement(n=2) | A medication statement is inferred from clinical events associated with orders, prescriptions written, pharmacy dispensing, procedural administrations, and other patient-reported information. Medication includes medicines, vaccines, and large-molecule biologic therapies. | administrationUnitCode | |||
| consumableCode | ATC codes | 6000 | |||