10.6.1Questionnaires

10.6.1.1Introduction

The FHIR Clinical Reasoning Module defines the Questionnaire resource. A Questionnaire is an organized collection of questions intended to solicit information from patients, providers or other individuals involved in the healthcare domain. They may be simple flat lists of questions or can be hierarchically organized in groups and sub-groups, each containing questions. The Questionnaire defines the questions to be asked, how they are ordered and grouped, any intervening instructional text and what the constraints are on the allowed answers. The results of a Questionnaire can be communicated using the QuestionnaireResponse resource.

Questionnaires cover the need to communicate data originating from forms used in medical history examinations, research questionnaires and sometimes full clinical specialty records. In many systems this data is collected using user-defined screens and forms. Questionnaires define specifics about data capture - exactly what questions were asked, in what order, what choices for answers were, etc. Each of these questions is part of the Questionnaire, and as such the Questionnaire is a separately identifiable Resource, whereas the individual questions are not. (Questionnaire questions can be linked to shared data elements using the Questionnaire.item.definition element.)

In addition to its use as a means for capturing data, Questionnaires can also be useful as a mechanism of defining a standardized 'presentation' of data that might already exist. For example, a peri-natal form or diabetes management form. In this use, the benefit is to expose a large volume of data in a predictable way that can be defined outside the user-interface design of the relevant system. The form might allow data to be edited or might be read-only. In some cases, the QuestionnaireResponse might not be intended to be persisted.

10.6.1.2Operations

HAPI implements the following operations for Questionnaires and QuestionnaireResponses:

• $questionnaire
• $populate
• $extract
• $package
• $data-requirements

10.6.1.3Questionnaire

The StructureDefinition/$questionnaire operation generates a Questionnaire from a given StructureDefinition. A question will be created for each core element or extension element found in the StructureDefinition.

10.6.1.4Populate

The Questionnaire/$populate operation generates a QuestionnaireResponse based on a specific Questionnaire, filling in answers to questions where possible based on information provided as part of the operation or already known by the server about the subject of the Questionnaire.

This implementation only allows for Expression-based population. Additional parameters have been added to support CQL evaluation.

10.6.1.5Extract

The QuestionnaireResponse/$extract operation takes a completed QuestionnaireResponse and converts it to a Bundle of resources by using metadata embedded in the Questionnaire the QuestionnaireResponse is based on. The extracted resources might include Observations, MedicationStatements and other standard FHIR resources which can then be shared and manipulated. When invoking the $extract operation, care should be taken that the submitted QuestionnaireResponse is itself valid. If not, the extract operation could fail (with appropriate OperationOutcomes) or, more problematic, might succeed but provide incorrect output.

This implementation allows for both Observation-based and Definition-based extraction.

10.6.1.6Package

The Questionnaire/$package operation for Questionnaire will generate a Bundle of resources that includes the Questionnaire as well as any related Library or ValueSet resources which can then be shared. This implementation follows the CRMI IG guidance for packaging artifacts.

10.6.1.7DataRequirements

The Questionnaire/$data-requirements operation for Questionnaire will generate a Library of type module-definition that returns the computed effective requirements of the artifact.

10.6.1.8Example Questionnaire

{
   "resourceType": "Questionnaire",
   "id": "ASLPA1",
   "meta": {
      "versionId": "1",
      "lastUpdated": "2023-05-09T19:02:10.538-06:00",
      "source": "#jucRbegv3NMJkZ8X"
   },
   "extension": [
      {
         "url": "http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeCapability",
         "valueCode": "shareable"
      },
      {
         "url": "http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeCapability",
         "valueCode": "computable"
      },
      {
         "url": "http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeCapability",
         "valueCode": "publishable"
      },
      {
         "url": "http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeRepresentationLevel",
         "valueCode": "structured"
      },
      {
         "url": "http://hl7.org/fhir/StructureDefinition/cqf-library",
         "valueCanonical": "http://example.org/sdh/dtr/aslp/Library/ASLPDataElements"
      }
   ],
   "url": "http://example.org/sdh/dtr/aslp/Questionnaire/ASLPA1",
   "name": "ASLPA1",
   "title": "ASLP.A1 Adult Sleep Studies",
   "status": "active",
   "experimental": false,
   "description": "Adult Sleep Studies Prior Authorization Form",
   "useContext": [
      {
         "code": {
            "system": "http://terminology.hl7.org/CodeSystem/usage-context-type",
            "code": "task",
            "display": "Workflow Task"
         },
         "valueCodeableConcept": {
            "coding": [
               {
                  "system": "http://fhir.org/guides/nachc/hiv-cds/CodeSystem/activity-codes",
                  "code": "ASLP.A1",
                  "display": "Adult Sleep Studies"
               }
            ]
         }
      }
   ],
   "item": [
      {
         "extension": [
            {
               "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-itemPopulationContext",
               "valueExpression": {
                  "language": "text/cql-identifier",
                  "expression": "Sleep Study"
               }
            }
         ],
         "linkId": "0",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-sleep-study-order",
         "text": "A sleep study procedure being ordered",
         "type": "group",
         "repeats": true,
         "item": [
            {
               "linkId": "1",
               "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-sleep-study-order#ServiceRequest.code",
               "text": "A sleep study procedure being ordered",
               "type": "choice",
               "answerValueSet": "http://example.org/sdh/dtr/aslp/ValueSet/aslp-a1-de1-codes-grouper"
            },
            {
               "linkId": "2",
               "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-sleep-study-order#ServiceRequest.occurrence[x]",
               "text": "Date of the procedure",
               "type": "dateTime"
            }
         ]
      },
      {
         "extension": [
            {
               "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
               "valueExpression": {
                  "language": "text/cql-identifier",
                  "expression": "Diagnosis of Obstructive Sleep Apnea"
               }
            }
         ],
         "linkId": "3",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-diagnosis-of-obstructive-sleep-apnea#Condition.code",
         "text": "Diagnosis of Obstructive Sleep Apnea",
         "type": "choice",
         "answerValueSet": "http://example.org/sdh/dtr/aslp/ValueSet/aslp-a1-de17"
      },
      {
         "extension": [
            {
               "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
               "valueExpression": {
                  "language": "text/cql-identifier",
                  "expression": "History of Hypertension"
               }
            }
         ],
         "linkId": "4",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-history-of-hypertension#Observation.value[x]",
         "text": "History of Hypertension",
         "type": "boolean"
      },
      {
         "extension": [
            {
               "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
               "valueExpression": {
                  "language": "text/cql-identifier",
                  "expression": "History of Diabetes"
               }
            }
         ],
         "linkId": "5",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-history-of-diabetes#Observation.value[x]",
         "text": "History of Diabetes",
         "type": "boolean"
      },
      {
         "extension": [
            {
               "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
               "valueExpression": {
                  "language": "text/cql-identifier",
                  "expression": "Neck Circumference"
               }
            }
         ],
         "linkId": "6",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-height#Observation.value[x]",
         "text": "Neck circumference (in inches)",
         "type": "quantity"
      },
      {
         "extension": [
            {
               "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
               "valueExpression": {
                  "language": "text/cql-identifier",
                  "expression": "Height"
               }
            }
         ],
         "linkId": "7",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-height#Observation.value[x]",
         "text": "Height (in inches)",
         "type": "quantity"
      },
      {
         "extension": [
            {
               "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
               "valueExpression": {
                  "language": "text/cql-identifier",
                  "expression": "Weight"
               }
            }
         ],
         "linkId": "8",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-weight#Observation.value[x]",
         "text": "Weight (in pounds)",
         "type": "quantity"
      },
      {
         "extension": [
            {
               "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
               "valueExpression": {
                  "language": "text/cql-identifier",
                  "expression": "BMI"
               }
            }
         ],
         "linkId": "9",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-bmi#Observation.value[x]",
         "text": "Body mass index (BMI)",
         "type": "quantity"
      }
   ]
}

10.6.1.9Example QuestionnaireResponse

{
   "resourceType": "QuestionnaireResponse",
   "id": "ASLPA1-positive-response",
   "extension": [
      {
         "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-questionnaireresponse-questionnaire",
         "valueReference": {
            "reference": "#ASLPA1-positive"
         }
      }
   ],
   "questionnaire": "http://example.org/sdh/dtr/aslp/Questionnaire/ASLPA1",
   "status": "in-progress",
   "subject": {
      "reference": "Patient/positive"
   },
   "item": [
      {
         "linkId": "0",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-sleep-study-order",
         "text": "A sleep study procedure being ordered",
         "item": [
            {
               "extension": [
                  {
                     "url": "http://hl7.org/fhir/StructureDefinition/questionnaireresponse-author",
                     "valueReference": {
                        "reference": "http://cqframework.org/fhir/Device/clinical-quality-language"
                     }
                  }
               ],
               "linkId": "1",
               "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-sleep-study-order#ServiceRequest.code",
               "text": "A sleep study procedure being ordered",
               "answer": [
                  {
                     "valueCoding": {
                        "system": "http://example.org/sdh/dtr/aslp/CodeSystem/aslp-codes",
                        "code": "ASLP.A1.DE2",
                        "display": "Home sleep apnea testing (HSAT)"
                     }
                  }
               ]
            },
            {
               "extension": [
                  {
                     "url": "http://hl7.org/fhir/StructureDefinition/questionnaireresponse-author",
                     "valueReference": {
                        "reference": "http://cqframework.org/fhir/Device/clinical-quality-language"
                     }
                  }
               ],
               "linkId": "2",
               "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-sleep-study-order#ServiceRequest.occurrence[x]",
               "text": "Date of the procedure",
               "answer": [
                  {
                     "valueDateTime": "2023-04-10T08:00:00.000Z"
                  }
               ]
            }
         ]
      },
      {
         "linkId": "0",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-sleep-study-order",
         "text": "A sleep study procedure being ordered",
         "item": [
            {
               "extension": [
                  {
                     "url": "http://hl7.org/fhir/StructureDefinition/questionnaireresponse-author",
                     "valueReference": {
                        "reference": "http://cqframework.org/fhir/Device/clinical-quality-language"
                     }
                  }
               ],
               "linkId": "1",
               "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-sleep-study-order#ServiceRequest.code",
               "text": "A sleep study procedure being ordered",
               "answer": [
                  {
                     "valueCoding": {
                        "system": "http://example.org/sdh/dtr/aslp/CodeSystem/aslp-codes",
                        "code": "ASLP.A1.DE14",
                        "display": "Artificial intelligence (AI)"
                     }
                  }
               ]
            },
            {
               "extension": [
                  {
                     "url": "http://hl7.org/fhir/StructureDefinition/questionnaireresponse-author",
                     "valueReference": {
                        "reference": "http://cqframework.org/fhir/Device/clinical-quality-language"
                     }
                  }
               ],
               "linkId": "2",
               "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-sleep-study-order#ServiceRequest.occurrence[x]",
               "text": "Date of the procedure",
               "answer": [
                  {
                     "valueDateTime": "2023-04-15T08:00:00.000Z"
                  }
               ]
            }
         ]
      },
      {
         "extension": [
            {
               "url": "http://hl7.org/fhir/StructureDefinition/questionnaireresponse-author",
               "valueReference": {
                  "reference": "http://cqframework.org/fhir/Device/clinical-quality-language"
               }
            }
         ],
         "linkId": "3",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-diagnosis-of-obstructive-sleep-apnea#Condition.code",
         "text": "Diagnosis of Obstructive Sleep Apnea",
         "answer": [
            {
               "valueCoding": {
                  "system": "http://example.org/sdh/dtr/aslp/CodeSystem/aslp-codes",
                  "code": "ASLP.A1.DE17",
                  "display": "Obstructive sleep apnea (OSA)"
               }
            }
         ]
      },
      {
         "extension": [
            {
               "url": "http://hl7.org/fhir/StructureDefinition/questionnaireresponse-author",
               "valueReference": {
                  "reference": "http://cqframework.org/fhir/Device/clinical-quality-language"
               }
            }
         ],
         "linkId": "4",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-history-of-hypertension#Observation.value[x]",
         "text": "History of Hypertension",
         "answer": [
            {
               "valueBoolean": true
            }
         ]
      },
      {
         "extension": [
            {
               "url": "http://hl7.org/fhir/StructureDefinition/questionnaireresponse-author",
               "valueReference": {
                  "reference": "http://cqframework.org/fhir/Device/clinical-quality-language"
               }
            }
         ],
         "linkId": "5",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-history-of-diabetes#Observation.value[x]",
         "text": "History of Diabetes",
         "answer": [
            {
               "valueBoolean": true
            }
         ]
      },
      {
         "extension": [
            {
               "url": "http://hl7.org/fhir/StructureDefinition/questionnaireresponse-author",
               "valueReference": {
                  "reference": "http://cqframework.org/fhir/Device/clinical-quality-language"
               }
            }
         ],
         "linkId": "6",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-height#Observation.value[x]",
         "text": "Neck circumference (in inches)",
         "answer": [
            {
               "valueQuantity": {
                  "value": 16,
                  "unit": "[in_i]",
                  "system": "http://unitsofmeasure.org",
                  "code": "[in_i]"
               }
            }
         ]
      },
      {
         "extension": [
            {
               "url": "http://hl7.org/fhir/StructureDefinition/questionnaireresponse-author",
               "valueReference": {
                  "reference": "http://cqframework.org/fhir/Device/clinical-quality-language"
               }
            }
         ],
         "linkId": "7",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-height#Observation.value[x]",
         "text": "Height (in inches)",
         "answer": [
            {
               "valueQuantity": {
                  "value": 69,
                  "unit": "[in_i]",
                  "system": "http://unitsofmeasure.org",
                  "code": "[in_i]"
               }
            }
         ]
      },
      {
         "extension": [
            {
               "url": "http://hl7.org/fhir/StructureDefinition/questionnaireresponse-author",
               "valueReference": {
                  "reference": "http://cqframework.org/fhir/Device/clinical-quality-language"
               }
            }
         ],
         "linkId": "8",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-weight#Observation.value[x]",
         "text": "Weight (in pounds)",
         "answer": [
            {
               "valueQuantity": {
                  "value": 185,
                  "unit": "[lb_av]",
                  "system": "http://unitsofmeasure.org",
                  "code": "[lb_av]"
               }
            }
         ]
      },
      {
         "extension": [
            {
               "url": "http://hl7.org/fhir/StructureDefinition/questionnaireresponse-author",
               "valueReference": {
                  "reference": "http://cqframework.org/fhir/Device/clinical-quality-language"
               }
            }
         ],
         "linkId": "9",
         "definition": "http://example.org/sdh/dtr/aslp/StructureDefinition/aslp-bmi#Observation.value[x]",
         "text": "Body mass index (BMI)",
         "answer": [
            {
               "valueQuantity": {
                  "value": 16.2,
                  "unit": "kg/m2",
                  "system": "http://unitsofmeasure.org",
                  "code": "kg/m2"
               }
            }
         ]
      }
   ]
}