ISO 27269:2021
Health informatics — International patient summary
This document defines the core data set for a patient summary document that supports continuity of care for a person and coordination of their healthcare. It is specifically aimed at supporting the use case’ scenario for ‘unplanned, cross border care’ and is intended to be an international patient summary (IPS). Whilst the data set is minimal and non-exhaustive, it provides a robust, well-defined core set of data items. The tight focus on this use case also enables the IPS to be used in planned care. This means that both unplanned and planned care can be supported by this data set within local and national contexts, thereby increasing its utility and value.
It uses the European Guideline from the eHN as the initial source for the patient summary requirements, then takes into consideration other international patient summary projects to provide an interoperable data set specification that has global application.
This document provides an abstract definition of a Patient Summary from which derived models are implementable. Due to its nature therefore, readers should be aware that the compliance with this document does not imply automatic technical interoperability; this result, enabled by this document, can be reached with the conformity to standards indicated in the associated technical specification and implementation guides.
This document does not cover the workflow processes of data entry, data collection, data summarization, subsequent data presentation, assimilation, or aggregation. Furthermore, this document does not cover the summarization act itself, i.e. the intelligence/skill/competence that results in the data summarization workflow.
It is not an implementation guide that is concerned with the various technical layers beneath the application layer. Implementation guidance for specifically jurisdictional concerns, e.g. Directives, terminologies, formats, etc., an example is specified in the associated Technical Specification[3].
In particular, representation by various coding schemes, additional structures and terminologies are not part of this document. Terminology and its binding are addressed in Reference [3]. The Identification of Medicinal Products standards (abbreviated to IDMP) are the recommended target for the Medication Summary related to this document but, prior to IDMP’s full implementation in practice, this IPS standard cannot insist in its use at this point in time and recognizes that interim schemes might be necessary until IDMP becomes established as a norm.
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Foreword
Introduction
1 Scope
2 Normative references
3 Terms and definitions
3.1 Healthcare
3.2 Healthcare actor
3.3 Healthcare matter
3.4 Healthcare activity
3.5 Healthcare planning
3.6 Time
3.7 Responsibility
3.8 Information Management
3.8.1 Concepts
3.8.2 Models
3.8.3 Data
3.8.4 Process
4 Abbreviations
5 Conformance
5.1 Introduction
5.2 IPS Conformance Detail
6 Descriptors for the IPS Data Set
6.1 Patterns within the IPS Data Set
6.1.1 General
6.1.2 Label Concept
6.1.3 List
6.1.4 Reference
6.1.5 Person Name
6.1.6 Coded Element
6.1.7 Date Time
6.1.8 Identifier
6.1.9 Address
6.1.10 Telecom
6.1.11 Organization Name
6.1.12 Text
6.1.13 Any
6.1.14 Range
6.1.15 Quantity
6.1.16 Period
6.1.17 General Time Specification
6.1.18 String
6.1.19 Ratio
6.2 Model Extensibility
7 Definition of the IPS Document (IPS)
7.1 Overview Description: THE IPS DOCUMENT (Table 4)
7.2 Detailed Description: THE IPS DOCUMENT
8 Definition for IPS Attribute Collection: PATIENT ATTRIBUTES
8.1 Overview Description: PATIENT ATTRIBUTES (Table 5)
8.2 Detailed Description: PATIENT ATTRIBUTES
9 Definition for IPS Attribute Collection: HEALTHCARE PROVIDER
9.1 Overview Description for HEALTHCARE PROVIDER (Table 6)
9.2 Detailed Description for HEALTHCARE PROVIDER
10 Definition for IPS Attribute Collection: PATIENT’S ADDRESS BOOK
10.1 Overview Description for PATIENT’S ADDRESS BOOK (Table 7)
10.2 Detailed Description for PATIENT’S ADDRESS BOOK
11 Definition for IPS Section: ADVANCE DIRECTIVES
11.1 Overview Description for ADVANCE DIRECTIVES (Table 8)
11.2 Detailed Description for ADVANCE DIRECTIVES
12 Definition for IPS Section: ALLERGIES and INTOLERANCES
12.1 Overview Description for ALLERGIES and INTOLERANCES (Table 9)
12.2 Detailed Description for ALLERGIES and INTOLERANCES
13 Definition for IPS Section: FUNCTIONAL STATUS
13.1 Overview Description for FUNCTIONAL STATUS (Table 10)
13.2 Detailed Description for FUNCTIONAL STATUS
14 Definition for IPS Section: HISTORY OF PAST PROBLEMS
14.1 Overview Description for HISTORY OF PAST PROBLEMS (Table 11)
14.2 Detailed Description for HISTORY OF PAST PROBLEMS
15 Definition for IPS Section: HISTORY OF PREGNANCY
15.1 Overview Description for HISTORY OF PREGNANCY (Table 12)
15.2 Detailed Description for HISTORY OF PREGNANCY
16 Definition for IPS Section: HISTORY OF PROCEDURES
16.1 Overview Description for HISTORY OF PROCEDURES (Table 13)
16.2 Detailed Description for HISTORY OF PROCEDURES
17 Definition for IPS Section: IMMUNIZATIONS
17.1 Overview Description for IMMUNIZATIONS (Table 14)
17.2 Detailed Description for IMMUNIZATIONS
18 Definition for IPS Section: MEDICAL DEVICES
18.1 Overview Description for MEDICAL DEVICES (Table 15)
18.2 Detailed Description for MEDICAL DEVICES
19 Definition for IPS Section: MEDICATION SUMMARY
19.1 Overview Description for MEDICATION SUMMARY (Tables 16 and 17)
19.2 The IPS Medication Summary and IDMP
19.3 Detailed Description for MEDICATION SUMMARY
20 Definition for IPS Section: PLAN OF CARE
20.1 Overview Description for PLAN OF CARE (Table 18)
20.2 Detailed Description for PLAN OF CARE
21 Definition for IPS Section: PROBLEMS
21.1 Overview Description for PROBLEMS (Table 19)
21.2 Detailed Description for PROBLEMS
22 Definition for IPS Section: RESULTS
22.1 Overview Description for RESULTS (Table 20)
22.2 Detailed Description for RESULTS
23 Definition for IPS Section: SOCIAL HISTORY
23.1 Overview Description for SOCIAL HISTORY (Table 21)
23.2 Detailed Description for SOCIAL HISTORY
24 Definition for IPS Section: VITAL SIGNS
24.1 Overview Description for VITAL SIGNS (Table 22)
24.2 Detailed Description for VITAL SIGNS
25 Definition for IPS Attribute Collection: Cross Border
25.1 Overview Description for CROSS BORDER (Table 23)
25.2 Detailed Description for CROSS BORDER
26 Definition for IPS Attribute Collection: Provenance Metadata
26.1 Overview Description for PROVENANCE (Table 24)
26.2 Detailed Description for PROVENANCE
Annex A (informative) The first IPS Scenario focussed on ‘unscheduled, cross-border care’
Annex B (informative) Explicit Trace between eHN Guideline Version 2
Annex C (informative) The eHN Guideline, the JIC PS Standards Set, and IPS
Bibliography
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Foreword
Introduction
1 Scope
2 Normative references
3 Terms and definitions
3.1 Healthcare
3.2 Healthcare actor
3.3 Healthcare matter
3.4 Healthcare activity
3.5 Healthcare planning
3.6 Time
3.7 Responsibility
3.8 Information Management
3.8.1 Concepts
3.8.2 Models
3.8.3 Data
3.8.4 Process
4 Abbreviations
5 Conformance
5.1 Introduction
5.2 IPS Conformance Detail
6 Descriptors for the IPS Data Set
6.1 Patterns within the IPS Data Set
6.1.1 General
6.1.2 Label Concept
6.1.3 List
6.1.4 Reference
6.1.5 Person Name
6.1.6 Coded Element
6.1.7 Date Time
6.1.8 Identifier
6.1.9 Address
6.1.10 Telecom
6.1.11 Organization Name
6.1.12 Text
6.1.13 Any
6.1.14 Range
6.1.15 Quantity
6.1.16 Period
6.1.17 General Time Specification
6.1.18 String
6.1.19 Ratio
6.2 Model Extensibility
7 Definition of the IPS Document (IPS)
7.1 Overview Description: THE IPS DOCUMENT (Table 4)
7.2 Detailed Description: THE IPS DOCUMENT
8 Definition for IPS Attribute Collection: PATIENT ATTRIBUTES
8.1 Overview Description: PATIENT ATTRIBUTES (Table 5)
8.2 Detailed Description: PATIENT ATTRIBUTES
9 Definition for IPS Attribute Collection: HEALTHCARE PROVIDER
9.1 Overview Description for HEALTHCARE PROVIDER (Table 6)
9.2 Detailed Description for HEALTHCARE PROVIDER
10 Definition for IPS Attribute Collection: PATIENT’S ADDRESS BOOK
10.1 Overview Description for PATIENT’S ADDRESS BOOK (Table 7)
10.2 Detailed Description for PATIENT’S ADDRESS BOOK
11 Definition for IPS Section: ADVANCE DIRECTIVES
11.1 Overview Description for ADVANCE DIRECTIVES (Table 8)
11.2 Detailed Description for ADVANCE DIRECTIVES
12 Definition for IPS Section: ALLERGIES and INTOLERANCES
12.1 Overview Description for ALLERGIES and INTOLERANCES (Table 9)
12.2 Detailed Description for ALLERGIES and INTOLERANCES
13 Definition for IPS Section: FUNCTIONAL STATUS
13.1 Overview Description for FUNCTIONAL STATUS (Table 10)
13.2 Detailed Description for FUNCTIONAL STATUS
14 Definition for IPS Section: HISTORY OF PAST PROBLEMS
14.1 Overview Description for HISTORY OF PAST PROBLEMS (Table 11)
14.2 Detailed Description for HISTORY OF PAST PROBLEMS
15 Definition for IPS Section: HISTORY OF PREGNANCY
15.1 Overview Description for HISTORY OF PREGNANCY (Table 12)
15.2 Detailed Description for HISTORY OF PREGNANCY
16 Definition for IPS Section: HISTORY OF PROCEDURES
16.1 Overview Description for HISTORY OF PROCEDURES (Table 13)
16.2 Detailed Description for HISTORY OF PROCEDURES
17 Definition for IPS Section: IMMUNIZATIONS
17.1 Overview Description for IMMUNIZATIONS (Table 14)
17.2 Detailed Description for IMMUNIZATIONS
18 Definition for IPS Section: MEDICAL DEVICES
18.1 Overview Description for MEDICAL DEVICES (Table 15)
18.2 Detailed Description for MEDICAL DEVICES
19 Definition for IPS Section: MEDICATION SUMMARY
19.1 Overview Description for MEDICATION SUMMARY (Tables 16 and 17)
19.2 The IPS Medication Summary and IDMP
19.3 Detailed Description for MEDICATION SUMMARY
20 Definition for IPS Section: PLAN OF CARE
20.1 Overview Description for PLAN OF CARE (Table 18)
20.2 Detailed Description for PLAN OF CARE
21 Definition for IPS Section: PROBLEMS
21.1 Overview Description for PROBLEMS (Table 19)
21.2 Detailed Description for PROBLEMS
22 Definition for IPS Section: RESULTS
22.1 Overview Description for RESULTS (Table 20)
22.2 Detailed Description for RESULTS
23 Definition for IPS Section: SOCIAL HISTORY
23.1 Overview Description for SOCIAL HISTORY (Table 21)
23.2 Detailed Description for SOCIAL HISTORY
24 Definition for IPS Section: VITAL SIGNS
24.1 Overview Description for VITAL SIGNS (Table 22)
24.2 Detailed Description for VITAL SIGNS
25 Definition for IPS Attribute Collection: Cross Border
25.1 Overview Description for CROSS BORDER (Table 23)
25.2 Detailed Description for CROSS BORDER
26 Definition for IPS Attribute Collection: Provenance Metadata
26.1 Overview Description for PROVENANCE (Table 24)
26.2 Detailed Description for PROVENANCE
Annex A (informative) The first IPS Scenario focussed on ‘unscheduled, cross-border care’
Annex B (informative) Explicit Trace between eHN Guideline Version 2
Annex C (informative) The eHN Guideline, the JIC PS Standards Set, and IPS
Bibliography