About the Workflow

Steps

From business perspective, the employee (care provider) visited the patient (Appointment / Encounter) and perform an activity of wound treatment.

New Wound

During a visit the nurse sees a new wound in foot. Probably Diabetic Foot Ulcer (DFU)

1. Add a new wound (Condition) to the system
2. The Condition mapped to the Patient directly ("subject").
3. In theory the Condition should have a dedicated Care Plan. By default all Conditions are part of the "General" care plan. This is something we need to implement.

Schedule a Follow up treatment

1. Create a Service Request. The SR is mapped to the Condition via "reasonReference".
2. A ServiceRequest should have a "reasonReference" which point to a Condition which is the main reason why this SR was created.
3. Assign the SR a Practitioner.
4. The Practitioner creates an Encounter (to schedule it) or map the SR to an existing Encounter.

(In theory the wound (condition) might be detected during an encounter for another reason. But still, every procedure should have a ServiceRequest and not made "out of the blue")

Observation and treatment

3. Add Observation of the wound, based on set of predefined properties.
4. Add Images (optional)
5. Do something (procedure), like replacing bondage (optional)
6. Set Alert (FHIR does NOT support it. Implementation probably an extension and let the Alert Server to import metadata from there).

FHIR

• Assume already exists: Patient, Encounter, ServiceRequest
• Assume a Condition of the wound already exists, or create new. According to FHIR: "Use Condition when a symptom requires long term management, tracking"
• Observation (of the wound)
• Procedure (optional, to take care of the wound).

FHIR Wound Profile

Most updated GIT hub: https://github.com/HL7/cimi-wound-assessment/ Their examples:https://github.com/HL7/cimi-wound-assessment/tree/master/source/examples

• A very good and detailed implementation Guide: http://build.fhir.org/ig/HL7/cimi-wound-assessment/branches/master/index.html Ignore all codes below and use only the ones in the link

https://cimi.hl7.org/submissions/september_2018/skinwoundig/fullcimi/site/modeldoc/index.html Examples how to use: https://confluence.hl7.org/pages/viewpage.action?pageId=58654725

Eventually, all objects should be associated to a care plan (directly or indirectly). In theory the system should create the appointments but the user should be able to creates ones too.

Wound Assessment

Business Requirements: https://www.sl-medical.co.il/forms/ LOINC Wound Assessment Panel: https://loinc.org/39135-9/ Missing a reference to wound smell

Implementation of FHIR Observation: http://www.hl7.org/fhir/observation.html

FYI: a new FHIR profile is in progress but not finished yet (Feb 2020). https://cimi.hl7.org/submissions/september_2018/skinwoundig/fullcimi/site/StructureDefinition-sw-WoundSizeObservation-model.html

Constants

category: "Exam". http://www.hl7.org/fhir/valueset-observation-category.html

Fields

• Body Site: https://loinc.org/39111-0/ . The Value Set is short, so it might be replaced with a custom SNOMED based list.
• Severity: 1 to 4. **Missing matching LOINC"
• Width: https://loinc.org/39125-0/
• Length: https://loinc.org/39126-8/
• Depth: https://loinc.org/39127-6/
• Deep /shallow: ???
• Drainage Amount: https://loinc.org/39116-9/
• Edema - Couldn't find LOINC value in the main panel https://loinc.org/39135-9/. SNOMED = ???
• Odor: https://loinc.org/72288-4/ not clear how to use it. missing answer panel
• Color: https://loinc.org/39132-6/
• Infection: Yes / No. https://loinc.org/45691-3/
• Description: free text
• Photographic Image: https://loinc.org/72170-4/

FHIR: Observation (Wound Assessment)

Rules:

• Category: always "Exam"