Repesentation of an Order for Procedures in FHIR

Question

A Procedure resource in FHIR does not have a status so you can't just represent it with status=planned for a future event being ordered or proposed directly. Is a future date sufficient to represent an order for a procedure?

Order resource documentation states the following which might imply a Procedure resource cannot be a target of an order.

Note that a resource may only be used for the order details if the definition for the resource used in the detail explicitly defines how it is known to be something requested, as opposed to (for instance) something that has happened. For some resources, such as a prescription, this is defined to be always true - it is always an instruction/request for something to be done, while other resources may have some kind of status element for this purpose. If the definition of the resource does not explicitly make it clear this, then it cannot be the target of an order.

An Encounter resource can have a planning status and a procedure can be associated with an encounter so one possible solution might be an Order resource with an Encounter [status=planned] and related Procedure resource.

For example, here is a FHIR XML representation of a biopsy procedure for a given patient:

Procedure Example

<Procedure xmlns="http://hl7.org/fhir">
  <subject>
    <reference value="Patient/example"/>
  </subject>
  <type>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="90105005"/>
      <display value="Biopsy of soft tissue of forearm (Procedure)"/>
    </coding>
    <text value="Biopsy of suspected melanoma L) arm"/>
  </type>
  <bodySite>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="368225008"/>
      <display value="Entire Left Forearm"/>
    </coding>
    <text value="Left forearm"/>
  </bodySite>
  <performer>
    <person>
      <reference value="Practitioner/example"/>
      <display value="Dr Bert Biopser"/>
    </person>
  </performer>
  <date>
    <start value="2014-10-03"/>
  </date>
  <followUp value="Review in clinic"/>
  <notes value="Standard Biopsy"/>
</Procedure>

So what's an appropriate FHIR representation for proposing or ordering a procedure?

Answer 1

As procedure stands, it cannot be used for an order. I have created a tracker task for this: http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=3001&start=

You have a few options:

• add a modifierExtension saying it's an order rather than something that happened
• use a future date, as you say, but once the future date becomes past, how do you know?
• deem that it's a future order if there's a order pointing to it - but what happens if you forget to check for the order? (Or don't know to, or the procedure becomes separated from it's order?)
• wait for the next version :-(

Answer 2

In general, we try not to use the "event" resources for orders - a separate resource will be introduced (just as DiagnosticOrder is used for Observation and MedicationPrescription is used for MedicationDispense and MedicationAdministration). In all likelihood, orders for procedures will be encompassed in the Referral resource which the PatientCare work group should have a relatively complete version posted in the development release by Sept. and a draft version in the next couple of months. (If you think there's value in having an order for procedures that's distinct from Referral, let us know - including what you think the difference is and where you've seen "procedure orders" used outside of referrals.)