Public Health JIRA updates

source/immunization/structuredefinition-Immunization.xml

@@ -567,7 +567,7 @@
     </element>
     <element id="Immunization.location">
       <path value="Immunization.location"/>
-      <short value="Where immunization occurred"/>
+      <short value="The service delivery location"/>
       <definition value="The service delivery location where the vaccine administration occurred."/>
       <min value="0"/>
       <max value="1"/>
@@ -1147,7 +1147,7 @@
       <short value="Dose number within series"/>
       <definition value="Nominal position in a series as intended by the practitioner administering the dose."/>
       <comment value="The use of an integer is preferred if known. Text should only be used in cases where an integer is not available (such as when documenting a recurring booster dose)."/>
-      <min value="1"/>
+      <min value="0"/>
       <max value="1"/>
       <type>
         <code value="string"/>

source/immunizationrecommendation/immunizationrecommendation-introduction.xml

@@ -5,25 +5,33 @@
 <a name="scope"></a>
 <h2>Scope and Usage</h2>
 <p>
-The ImmunizationRecommendation resource is intended to cover communication of a specified patient's immunization recommendations and status across all healthcare disciplines in all care settings and all regions. The set of customized (for the patient) recommendations is based on the comparison of the patient's immunization history with a set of published recommendations (protocols).
+The ImmunizationRecommendation resource is intended to cover the expression of a customized set of immunization recommendations and status for a specific individual. This can include recommending future doses to further the individual along the path to immunity and/or indicating that vaccination is not needed (e.g., an immunity or contraindication negates the need for additional doses, the patient has aged out of a series, a patient has completed a series). Recommendations may be used to initiate clinical activity such as the ordering and administration of a vaccine or may be used for non-clinical purposes such as presentation of vaccination credentials, satisfaction of school enrollment requirements or public health purposes. While not explicitly expressed in the resource itself, the "intent" of an ImmunizationRecommendation resource is always considered to be "proposal".  
 </p>
 <p>
-Additionally, the ImmunizationRecommendation resource is expected to cover key concepts related to the querying of a patient's immunization recommendations and status. This resource - through consultation with the Public Health work group - is believed to meet key use cases and information requirements as defined in the existing <a href="https://www.hl7.org/implement/standards/product_brief.cfm?product_id=186">HL7 v3</a> POIZ domain and Immunization Domain Analysis Model.
+An ImmunizationRecommendation is a point-in-time representation of an individual's data compared against a set of guidelines designed by healthcare professionals to protect individuals against a wide range of vaccine preventable diseases. These sets of guidelines go by various names in different locales, but for the sake of what follows, they will be referred to as a “schedule”. Schedules are often age-based but can also contain recommendations based on other information about the patient including things like allergies, underlying medical conditions, prescribed medications, personal behaviors and other attributes. For example, in the United States, all infants are recommended to receive their first dose of the polio vaccine by 2 months of age while healthcare professionals are recommended to be vaccinated against Hepatitis B if they are routinely exposed to blood products. An individualized immunization recommendation is typically the product of a clinical decision support (CDS) engine which takes the individual's data and a machine computable schedule as inputs to evaluate the patient's current immunization status and forecast future needs. Note that an immunization recommendation may also indicate that further vaccination is not required for a given target disease if the individual has completed their path to immunity. A comparison of the individual's data against different guidelines may result in a different set of recommendations. Also note that schedules themselves may evolve over time potentially resulting in new recommendations for a given individual. As noted in the figure below, a set of individualized immunization recommendations may then be used for a variety of purposes. Perhaps the most obvious usage is as the basis for a healthcare provider to develop and implement a plan to vaccinate the individual. However, other usages are possible including as a basis for vaccine credentialling, meeting school admission requirements, and performing public health activities. Because the recommendations for an individual can change over time, the data contained in an ImmunizationRecommendation resource is expected to be the basis for clinical action for only a short period of time. 
+</p>
+<p>
+An individual recommendation in the ImmunizationRecommendation resource will often relate to the recommendation of a specific dose of vaccine. The base ImmunizationRecommendation is silent on the time frame for the recommended administration date for a recommendation contained in the resource. That is, it is a system decision about how far in advance (1 day, 1 week, 6 weeks, 6 months, etc) of the recommendation administration date a recommendation is made. A recommendation may also be used to indicate that additional doses are not needed for some reason (such as the series is complete, the patient has aged out of the series, the patient is immune through some other mechanism or additional doses are contraindicated). This functionality may be important to convey to end users that they should not take action.
+</p>
+<p>
+The display of immunization recommendations to end users is the responsibility of the system using the data contained in the ImmunizationRecommendation resource. Use case specific Implementation Guides can define specific display or usage expectations (if any) of systems using the recommendations contained in the resource.
 </p>
 </div>
 
 <div>
 <a name="bnr"></a>
 <h2>Boundaries and Relationships</h2>
+
 <p>
-This resource references the following resources:
-</p>
-<ul>
-    <li>Patient</li>
-    <li>Organization</li>
-    <li>Immunization</li>
-    <li>ImmunizationEvaluation</li>
-</ul>
+As noted above, the comparison of an individual's data against a schedule includes an evaluation of each prior dose of vaccine against the guidelines set forth in the schedule. The outcome of this evaluation is either the validation of the prior dose (that is, the dose is “valid” and advances the individual on the path to immunity) or the determination that the prior dose was “invalid” for some reason and cannot count towards meeting the guidelines in the schedule. The evaluation outcome for a given dose of vaccine can be expressed in the ImmunizationEvaluation resource. 
+</p>
+<p>An ImmunizationRecommendation resource may reference the relevant Immunization and ImmunizationEvaluation resources that underly the recommendation. Additional resources may be referenced where they document other factors (such as underlying medical conditions, behaviors, etc) which impact the recommendation.
+</p>
+<p>The recommendations contained within an ImmunizationRecommendation resource may be used to initiate a set of clinical activities leading to the administration and documentation of one or more doses of vaccine. Where a record of an order to administer a vaccine is required, the MedicationRequest resource is used. The value of MedicationRequest.intent is used to distinguish between a plan to vaccinate and an authorized order. MedicationRequest.basedOn may be used to link the order to the initiating ImmunizationRecommendation. The documentation of the administration of the vaccine should be accomplished through the use of the Immunization resource. 
+</p>
+<p>Note that the ImmunizationRecommendation resource allows the inclusion of multiple recommendations in a single instance of the resource. Where the output of the evaluation process results in only a single recommendation, the use of MedicationRequest where .intent is valued “proposal” is allowed as an alternative to the ImmunizationRecommendation resource if it simplifies the subsequent clinical workflow.
+</p>
+<img src="immunizationrecommendation.png"/>
 </div>
 
 </div>

source/immunizationrecommendation/structuredefinition-ImmunizationRecommendation.xml

@@ -206,7 +206,7 @@
       <path value="ImmunizationRecommendation.recommendation"/>
       <short value="Vaccine administration recommendations"/>
       <definition value="Vaccine administration recommendations."/>
-      <comment value="A given instance of the .recommendation backbone element should correspond to a single recommended administration."/>
+      <comment value="A given instance of the .recommendation backbone element should correspond to a single recommended administration or the entire immunization series when there is no recommended administration"/>
       <min value="1"/>
       <max value="*"/>
       <type>

source/questionnaireresponse/bundle-QuestionnaireResponse-search-params.xml

@@ -166,7 +166,7 @@
           <valueString value="QuestionnaireResponse.source"/>
         </extension>
         <url value="http://hl7.org/fhir/build/SearchParameter/QuestionnaireResponse-source"/>
-        <description value="The individual providing the information reflected in the questionnaire respose"/>
+        <description value="The individual providing the information reflected in the questionnaire response"/>
         <code value="source"/>
         <type value="reference"/>
         <expression value="QuestionnaireResponse.source"/>

tools/history/release3/profiles-resources.xml

@@ -13590,7 +13590,7 @@
               <name value="source"/>
               <definition value="http://hl7.org/fhir/SearchParameter/QuestionnaireResponse-source"/>
               <type value="reference"/>
-              <documentation value="The individual providing the information reflected in the questionnaire respose"/>
+              <documentation value="The individual providing the information reflected in the questionnaire response"/>
             </searchParam>
             <searchParam>
               <name value="status"/>

tools/history/release3/search-parameters.xml

@@ -39030,7 +39030,7 @@
         <code value="source"/>
         <base value="QuestionnaireResponse"/>
         <type value="reference"/>
-        <description value="The individual providing the information reflected in the questionnaire respose"/>
+        <description value="The individual providing the information reflected in the questionnaire response"/>
         <expression value="QuestionnaireResponse.source"/>
         <xpath value="f:QuestionnaireResponse/f:source"/>
         <xpathUsage value="normal"/>