HL7 FHIR Malaysia Core (MY Core) Implementation Guide
2.0.0 - ci-build

HL7 FHIR Malaysia Core (MY Core) Implementation Guide - Local Development build (v2.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Patient Records

Patient demographics and other administrative information about a patient is stored as a Patient (MY Core) record.

Sample Data and API

Here are some common APIs used in HIE.

[base] = address url e.g. "https://fhir.hie.moh.gov.my/baseR4/"
@patientId = unique patient ID defined by the source system e.g "patient-sample"
@patientIdentifier = patient identifier such as a MyKad number or MRN e.g "HIE-00000003"

Sample Description Sample Body API Method API
Create/Update patient record

1.MyKad identifier,

2.Newborn identifier,

3.Passport identifier,

4.Unknown identifier

 PUT [base]/Patient/@patientId
Retrieve patient record with patient ID - GET [base]/Patient/@patientId
Retrieve patient record with identifier - GET [base]/Patient?identifier=@patientIdentifier

Identifier Type

The Patient (MY Core) profile supports several types of identifiers, however each record must at least have a facility patient MRN (Medical Record Number) Patient.identifier.where (system ='http://fhir.hie.moh.gov.my/sid/patient-mrn').value.

  • MyKad (the Malaysian national identity card) or MyKid (the Malaysian national identity card for children below 12 years of age) is stored as Patient.identifier.where (system ='http://fhir.hie.moh.gov.my/sid/my-kad-no').value.
  • Army identifier is stored as Patient.identifier.where (system ='http://fhir.hie.moh.gov.my/sid/army-no').value.
  • Police identifier is stored as Patient.identifier.where (system ='http://fhir.hie.moh.gov.my/sid/police-no').value.
  • Newborn identifier format according to the SMRP (Sistem Maklumat Rawatan Pesakit, the Malaysian Healthcare Information System) standard is [MotherIdentifier] E/[Child No]. Example "921105146670 E/1".
    • It is stored as Patient.identifier.where (system ='http://fhir.hie.moh.gov.my/sid/newborn-no').value.
    • However, it is not mandatory for a source system to send in this format.
  • Other types of identifier is stored as Patient.identifier.where (system ='http://fhir.hie.moh.gov.my/sid/others-no').value.
    • This includes unknown patients where HIE format is [facility mnemonic]-UNK-[last 2 year digit][6 digit running number]. Example, "HTJ-UKN-23000006".
    • However, it is not mandatory for a source system to send in this format.

Golden Record

Due to the scope of integration, a single individual is expected to have multiple patient records from various source systems in the HIE. These records are linked together under one golden record using a function known as Master Data Management (MDM) developed by smileCDR.

The diagram below shows an example of records from various source systems linked by a golden record in HIE.

EID

The server will link multiple patient records to a single golden record based on these 4 elements:

  • Name (given or text value) Patient.name
  • Birth Date Patient.birthDate
  • Any Identifier Patient.identifier.value
  • Gender Patient.gender

For each patient record created in the HIE server, the server will check if a golden record with the above details matches with any existing golden record in the server. If there is a match, it will link the new registration to the golden record. If no matches exist, a new golden record will be created to be linked to the newly created patient record.

Merge and Unmerge Record

This section briefly explains the concept of the merge and unmerge functionality in the HIE. However, it is done mainly on a case by case basis using the Rekod Pesakit (Provider Portal) interface only. Generally the scenarios are as follows:

  • If multiple patient records are found to be duplicates, they can be linked together, as described below:

    • When a user detects that there are duplicate records related to the same patient, then they can choose to perform a merge record.
    • A qualified user can select the main record (the one with most complete or correct information) as the golden record and merge it with the duplicate record.
    • The merged record will link with the new golden record and inactivate the duplicate golden record.

merge mdm

  • If a patient's records are found to be wrongly matched, they can be separated, as described below:

    • When a user detects that two records were mistakenly matched when they are, in reality, 2 different patients, they can then choose to unmerge these records
    • A qualified user can select the wrongly matched records and unmerge them from the original golden record.
    • This will create a new golden record with the detached record.
unmerge mdm