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

Pharmacy Integration

Integration between the Malaysian Ministry of Health Pharmacy Information System (PhIS) with HIE falls within HIE scope of deliverables.

Objective

This section is to provide a reference point and integration use case scenario for developers. It is also used as a documentation of high level integration agreement between HIE and PhIS

Overview

These are the integration points agreed upon:

No Integration Point Data From Data To Frequency Remark
1 Master Drug List PhIS IWP HIE Daily HIE initiates existing IWP API with last synced date parameter to get latest Master Data
2 Facility Drug List PhIS IWP HIE Daily HIE initiates PhIS API with last synced date parameter to get the latest facility drug master
3 Patient Registration PhIS HIE Daily PhIS initiates HIE FHIR API to send the latest records
4 Allergy PhIS HIE Daily PhIS initiates HIE FHIR API to send the latest records
5 Allergy Negation Statement PhIS HIE Daily PhIS initiates HIE FHIR API to send the latest records
6 Medical Therapy Adherence Clinic (MTAC) summary PhIS HIE Daily PhIS initiates HIE FHIR API to send the latest records. Submits upon completed
7 Adverse Drug Reaction (ADR) Report PhIS HIE Daily PhIS initiates HIE FHIR API to send the latest records
8 Medication Counselling (MC) summary PhIS HIE Daily PhIS initiates HIE FHIR API to send the latest records. Submits upon completed
9 Medication Order - - No Integration Presciption will be done in Rekod Pesakit and printed. Pharmacist will then transcribe the prescription note into PhIS manually
10 Encounter Registration - - No Integration Refer PhIS for encounter record
11 TDM Reporting - - No Integration Refer to Laboratory Information System (LIS)
12 Dispensing - - No Integration Refer to PhIS for dispensing records
13 VC Scheduling & Appointment - - No Integration Virtual Consultation, Scheduling and Appointment in Rekod Pesakit

Integration Point

Patient Registration

Scenario: PhIS will send patient record to HIE.

Related Profile: Patient (MY Core)

Example JSON 
{
    "resourceType": "Patient",
    "id": "example-patient-phis",
    "meta": {
        "versionId": "4",
        "lastUpdated": "2022-12-19T06:54:52.308+08:00",
        "source": "http://phis.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Patient-my-core"
        ]
    },
    "extension":  [
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core",
            "extension":  [
                {
                    "url": "recorder",
                    "valueReference": {
                        "display": "First Recorder Practitioner Name"
                    }
                },
                {
                    "url": "recordedDate",
                    "valueDateTime": "2022-12-19T12:34:00+08:00"
                },
                {
                    "url": "lastUpdater",
                    "valueReference": {
                        "display": "Last Updater Practitioner Name"
                    }
                }
            ]
        },
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/education-level-my-core",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/education-level-my-core",
                        "code": "4",
                        "display": "tertiary"
                    }
                ]
            }
        },
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/religion-my-core",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/religion-my-core",
                        "code": "1",
                        "display": "Islam"
                    }
                ]
            }
        },
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/ethnic-my-core",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/ethnic-my-core",
                        "code": "01",
                        "display": "Melayu"
                    }
                ]
            }
        }
    ],
    "identifier":  [
        {
            "system": "http://fhir.hie.moh.gov.my/sid/my-kad-no",
            "value": "921005141234"
        },
        {
            "system": "http://fhir.hie.moh.gov.my/sid/patient-mrn",
            "value": "PHIS-123"
        }
    ],
    "active": true,
    "name":  [
        {
            "extension":  [
                {
                    "url": "http://fhir.hie.moh.gov.my/StructureDefinition/person-title-my-core",
                    "valueCodeableConcept": {
                        "coding":  [
                            {
                                "system": "http://fhir.hie.moh.gov.my/CodeSystem/person-title-my-core",
                                "code": "L001",
                                "display": "Encik"
                            }
                        ]
                    }
                }
            ],
            "given":  [
                "PHIS patient name example"
            ]
        }
    ],
    "telecom":  [
        {
            "system": "phone",
            "value": "014454120315"
        },
        {
            "system": "email",
            "value": "hieperson@gmail.com"
        }
    ],
    "gender": "male",
    "birthDate": "1992-10-05",
    "deceasedBoolean": false,
    "address":  [
        {
            "extension":  [
                {
                    "url": "http://fhir.hie.moh.gov.my/StructureDefinition/address-district-my-core",
                    "valueCodeableConcept": {
                        "coding":  [
                            {
                                "system": "http://fhir.hie.moh.gov.my/CodeSystem/district-my-core",
                                "code": "0505",
                                "display": "Seremban"
                            }
                        ]
                    }
                },
                {
                    "url": "http://fhir.hie.moh.gov.my/StructureDefinition/address-state-my-core",
                    "valueCodeableConcept": {
                        "coding":  [
                            {
                                "system": "http://fhir.hie.moh.gov.my/CodeSystem/state-my-core",
                                "code": "05",
                                "display": "Negeri Sembilan"
                            }
                        ]
                    }
                }
            ],
            "use": "home",
            "line":  [
                "No. 1, Jalan Bangsar 7/3"
            ],
            "city": "Laman Pelangi",
            "postalCode": "02196",
            "country": "MYS"
        }
    ],
    "contact":  [
        {
            "name": {
                "given":  [
                    "PHIS contact name example"
                ]
            },
            "telecom":  [
                {
                    "system": "phone",
                    "value": "01527893031",
                    "use": "mobile"
                }
            ],
            "gender": "male"
        }
    ],
    "managingOrganization": {
        "reference": "Organization/PHIS",
        "display": "Pharmacy Information System (PhIS)"
    }
}
API
Operation Address Request Method Example
Create Record [base]/Patient/@FacilityMrnIdentifier PUT https://fhir.hie.moh.gov.my/baseR4/Patient/HTJ-PHIS-123
Update Record [base]/Patient/@FacilityMrnIdentifier PUT https://fhir.hie.moh.gov.my/baseR4/Patient/HTJ-PHIS-123
Read Record [base]/Patient/@FacilityMrnIdentifier GET https://fhir.hie.moh.gov.my/baseR4/Patient/HTJ-PHIS-123
Mapping
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Profile Profile this resource claims to conform to 1..1 http://fhir.hie.moh.gov.my/StructureDefinition/Patient-my-core Patient.meta.profile Canonical
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Identification (My Kad) My Kad no. identifier 0..1 At least 1 identifier Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/my-kad-no String
Identification (Passport) Passport no. identifier 0..1 At least 1 identifier Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/passport-no String
Identification (Army) Army no. identifier 0..1 At least 1 identifier Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/army-no String
Identification (Police) Police no. identifier 0..1 At least 1 identifier Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/police-no String
Identification (MRN no) MRN no. identifier 1..1 MRN mandatory from source system Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/patient-mrn String
Identification (Other) Other no. identifier 0..1 At least 1 identifier Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/others-no String
Identification (Unknown) Unknown no. identifier 0..1 At least 1 identifier Patient.identifier.value where system=http://fhir.hie.moh.gov.my/sid/unknown-no String
Child Whether or not this record is a child record 1..1 If Identification (Newborn) value exist, else 0..1 Patient.identifier.extension.extension.valueBoolean where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/child-identification-my-core and Patient.extension.extension.url=child Boolean
ChildType Which guardian is child using identifier (mother/father/guardian) 1..1 If Identification (Newborn) value exist, else 0..1 ValueSetChildIdentificationType (MY Core) Patient.identifier.extension.extension.valueCodeableConcept where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/child-identification-my-core and Patient.extension.extension.url=childType CodeableConcept
ChildNo Child number 0..1 Patient.identifier.extension.extension.valueQuantity where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/child-identification-my-core and Patient.extension.extension.url=childNo Integer
Parent No. (Mother's ID) Guardian no. identifier 1..1 If Identification (Newborn) value exist, else 0..1 Patient.identifier.extension.extension.valueString where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/child-identification-my-core and Patient.extension.extension.url=parentIdentification String
Title Title given to patient 1..1 ValueSetPersonTitle (MY Core) Patient.name.extension.valueCodeableConcept.coding.code where system=http://fhir.hie.moh.gov.my/StructureDefinition/person-title-my-core
Name Given name 1..1 Patient.name.given String
Gender The gender of a person used for administrative purposes 1..1 ValueSetAdministrativeGender (MY Core) Patient.gender Code
Birth Date The date of birth for the individual 1..1 FHIR Format YYYY-MM-DD Patient.birthDate Date
Ethnicity Ethnicity of individual 0..1 ValueSetEthnic (MY Core) Patient.extension.valueCodeableConcept.coding.code where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/ethnic-my-core CodeableConcept
Religion Religion of individual 0..1 ValueSetReligion (MY Core) Patient.extension.valueCodeableConcept.coding.code where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/religion-my-core CodeableConcept
Education Level Education level of individual 0..1 ValueSetEducationLevel (MY Core) Patient.extension.valueCodeableConcept.coding.code where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/education-level-my-core CodeableConcept
Phone Number Phone number of individual 0..* Patient.telecom.value where Patient.telecom.system=phone String
Email Address Email number of indivdual 0..1 Patient.telecom.value where Patient.telecom.system=email String
Deceased Status Indicates if the individual is deceased or not 0..1 Patient.deceasedBoolean Boolean
Status Whether this patient's record is in active use 0..1 Patient.active Boolean
Source System Source System that is the custodian of the patient record 1..1 Hardcode value as "Organization/PHIS" Patient.managingOrganization.reference Reference
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Line Street name, number, direction & P.O. Box etc. 0..1 Patient.address.line String
Postal Code Postal code for area 0..1 Patient.address.postalCode String
Country Country - a nation as commonly understood or generally accepted. 0..1 Patient.country String
State Sub-unit of country 0..1 ValueSetState (MY Core) Patient.address.extension.valueCodeableConcept.coding.code where Patient.address.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/address-state-my-core CodeableConcept
District District name 0..1 ValueSetDistrict (MY Core) Patient.address.extension.valueCodeableConcept.coding.code where Patient.address.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/address-district-my-core CodeableConcept
City Name of city, town etc. 0..1 Patient.address.city String
Name A name associated with the contact person 0..1 Patient.contact.name.given String
Gender The gender of a person used for administrative purposes 0..1 ValueSetAdministrativeGender (MY Core) Patient.contact.gender Code
Phone Number Phone number of contact person 0..1 Patient.contact.telecom.value where Patient.contact.telecom.system=phone String
Email Address Email number of contact person 0..1 Patient.contact.telecom.value where Patient.contact.telecom.system=email String
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Line Street name, number, direction & P.O. Box etc. 0..1 Patient.contact.address.line String
Postal Code Postal code for area 0..1 Patient.contact.address.postalCode String
Country Country - a nation as commonly understood or generally accepted 0..1 Patient.contact.country String
State Sub-unit of country 0..1 ValueSetState (MY Core) Patient.contact.address.extension.valueCodeableConcept.coding.code where Patient.address.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/address-state-my-core CodeableConcept
District District name 0..1 ValueSetDistrict (MY Core) Patient.contact.address.extension.valueCodeableConcept.coding.code where Patient.address.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/address-district-my-core CodeableConcept
City Name of city, town etc. 0..1 Patient.contact.address.city String
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Recorder Practitioner who first recorded this encounter 0..1 Patient.extension.audit.recorder.valueReference.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=recorder String
Recorded Date Date encounter was first recorded 0..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 Patient.extension.audit.recordedDate.valueDateTime.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=recordedDate DateTime
Updator Practitioner who last updated this encounter 0..1 Patient.extension.audit.lastUpdater.valueReference.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=lastUpdater String
Last Updated Last encounter updated date 0..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 Patient.meta.lastUpdated DateTime (SystemGenerated)

Encounter Registration

Scenario: PhIS will send encounter record to HIE.

Related Profile: Encounter (MY Core)

Example JSON 
{
    "resourceType": "Encounter",
    "id": "example-encounter-phis",
    "meta": {
        "source": "http://phis.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Encounter-my-core"
        ]
    },
    "extension":  [
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core",
            "extension":  [
                {
                    "url": "recorder",
                    "valueReference": {
                        "display": "First Recorder Practitioner Name"
                    }
                },
                {
                    "url": "recordedDate",
                    "valueDateTime": "2022-12-19T12:34:00+08:00"
                },
                {
                    "url": "lastUpdater",
                    "valueReference": {
                        "display": "Last Updater Practitioner Name"
                    }
                }
            ]
        }
    ],
    "identifier":  [
        {
            "system": "http://fhir.hie.moh.gov.my/sid/encounter-id",
            "value": "PHIS-ENC-2212000101"
        }
    ],
    "status": "finished",
    "statusHistory":  [
        {
            "status": "arrived",
            "period": {
                "start": "2022-12-19T12:34:00+08:00",
                "end": "2022-12-19T12:45:14+08:00"
            }
        },
        {
            "status": "in-progress",
            "period": {
                "start": "2022-12-19T12:45:14+08:00",
                "end": "2022-12-19T14:23:08+08:00"
            }
        }
    ],
    "class": {
        "system": "http://fhir.hie.moh.gov.my/CodeSystem/encounter-class-my-core",
        "code": "VR",
        "display": "Virtual"
    },
    "type":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/specialty-my-core",
                    "code": "543",
                    "display": "Medication Counselling (MC)"
                }
            ]
        }
    ],
    "serviceType": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/service-type-my-core",
                "code": "VCI",
                "display": "Individual Virtual Consultation"
            }
        ]
    },
    "subject": {
        "reference": "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|PHIS-123"
    },
    "participant":  [
        {
            "type":  [
                {
                    "coding":  [
                        {
                            "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
                            "code": "ATND",
                            "display": "attender"
                        }
                    ]
                }
            ],
            "period": {
                "start": "2022-12-19T12:45:14+08:00"
            },
            "individual": {
                "display": "Primary Attender Practitioner Name"
            }
        }
    ],
    "period": {
        "start": "2022-12-19T12:34:00+08:00",
        "end": "2022-12-19T14:23:08+08:00"
    },
    "diagnosis":  [
        {
            "condition": {
                "display": "Allergic Reaction to Penicillin"
            },
            "use": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/diagnosis-role-my-core",
                        "code": "01",
                        "display": "Main Diagnosis"
                    }
                ]
            }
        },
        {
            "condition": {
                "display": "Asthma"
            },
            "use": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/diagnosis-role-my-core",
                        "code": "08",
                        "display": "Other Diagnosis"
                    }
                ]
            }
        }
    ],
    "serviceProvider": {
        "reference": "Organization/11-05060009"
    }
}
API
Operation Address Request Method Example
Create Record [base]/Encounter/@FacilityRnIdentifier PUT https://fhir.hie.moh.gov.my/baseR4/Encounter/HTJ-PHIS-ENC-123
Update Record [base]/Encounter/@FacilityRnIdentifier PUT https://fhir.hie.moh.gov.my/baseR4/Encounter/HTJ-PHIS-ENC-123
Read Record [base]/Encounter/@FacilityRnIdentifier GET https://fhir.hie.moh.gov.my/baseR4/Encounter/HTJ-PHIS-ENC-123
Mapping
HIE Item Element Description Cardinality PHIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Profile Profile this resource claims to conform to 1..1 http://fhir.hie.moh.gov.my/StructureDefinition/Encounter-my-core Encounter.meta.profile Canonical
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Identifier Identifier(s) by which this encounter is known 1..1 Encounter.identifier.value where system=http://fhir.hie.moh.gov.my/sid/encounter-id String
Latest Status Current state of the encounter. 1..1 ​ValueSetEncounterStatus (MY Core) Encounter.status Code
Latest Status Start Date Start period of current status 1..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 Encounter.period.start DateTime
Latest Status End Date End period of current status 0..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 Encounter.period.end DateTime
StatusHistory Past state of the encounter 0..* ​ValueSetEncounterStatus (MY Core) Encounter.statusHistory.status Code
StatusHistory Start Date Start period of past status 0..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 Encounter.statusHistory.status.period.start DateTime
StatusHistory End Date End period of past status 0..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 Encounter.statusHistory.status.period.end DateTime
Encounter Type Classification of the encounter 1..1 ValueSetEncounterClass (MY Core) Encounter.class.code Coding
ServiceType Broad categorization of the service that is to be provided 1..1 ValueSetServiceType (MY Core) Encounter.serviceType.coding.code CodeableConcept
Service The type of encounter 1..1 ValueSetSpecialty (MY Core) Encounter.type.coding.code CodeableConcept
Subject The patient or group present at the encounter 1..1 Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|@phisMrnNo" Encounter.subject.reference Reference
Primary Attender Primary attender to this encounter 0..1 Encounter.participant.individual.display where Encounter.type.coding.code=ATND String
Primary Attender Attended Date Start time of primary attender 0..1 Encounter.participant.period.start DateTime
Diagnosis The list of diagnosis relevant to this encounter 0..* Encounter.diagnosis.condition.display String
Diagnosis Role The type of diagnosis this condition represents 1..1 if Diagnosis specified ValueSetDiagnosisRole (My Core) Encounter.diagnosis.use.coding.code CodeableConcept
Service Provider The organization (facility) responsible for this encounter 1..1 Reference facility related by "Organization/@OrganizationPikId" Encounter.serviceProvider.reference Reference
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Recorder Practitioner who first recorded this encounter 0..1 Patient.extension.audit.recorder.valueReference.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=recorder String
Recorded Date Date encounter was first recorded 0..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 Patient.extension.audit.recordedDate.valueDateTime.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=recordedDate DateTime
Updator Practitioner who last updated this encounter 0..1 Patient.extension.audit.lastUpdater.valueReference.display where Patient.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core and Patient.extension.extension.url=lastUpdater String
Last Updated Last encounter updated date 0..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 Patient.meta.lastUpdated DateTime (SystemGenerated)

AllergyIntolerance

Scenario: PhIS will send allergy record to HIE.

Related Profile: AllergyIntolerance (MY Core)

Example JSON 

    {
        "resourceType": "AllergyIntolerance",
        "id": "example-allergy-phis",
        "meta": {
            "lastUpdated": "2022-08-17T10:24:11.265+08:00",
            "source": "http://phis.moh.gov.my",
            "profile": [
                "http://fhir.hie.moh.gov.my/StructureDefinition/AllergyIntolerance-my-core"
            ]
        },
        "extension": [
            {
                "url": "http://fhir.hie.moh.gov.my/StructureDefinition/formulary-boolean-my-core",
                "valueBoolean": true
            }
        ],
        "clinicalStatus": {
            "coding": [
                {
                    "system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical",
                    "code": "active",
                    "display": "Active"
                }
            ]
        },
        "verificationStatus": {
            "coding": [
                {
                    "system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-verification",
                    "code": "confirmed",
                    "display": "Confirmed"
                }
            ]
        },
        "category": [
            "medication"
        ],
        "code": {
            "coding": [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/active-ingredient-my-core",
                    "code": "41",
                    "display": "Adenine"
                }
            ]
        },
        "patient": {
            "reference": "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|PHIS-123"
        },
        "encounter": {
            "reference": "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/encounter-id|PHIS-ENC-2212000101"
        },
        "recordedDate": "2022-06-25T11:00:00.000+08:00",
        "recorder": {
            "display": "Recorder Practitioner Name"
        },
        "asserter": {
            "display": "Asserter Practitioner Name"
        },
        "lastOccurrence": "2022-06-20T09:00:00.000+08:00",
        "reaction": [
            {
                "extension": [
                    {
                        "url": "http://fhir.hie.moh.gov.my/StructureDefinition/formulary-boolean-my-core",
                        "valueBoolean": true
                    }
                ],
                "substance": {
                    "coding": [
                        {
                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-my-core",
                            "code": "PNA00013",
                            "display": "Kabiven Central 1900kcal, 2.053L"
                        }
                    ]
                },
                "manifestation": [
                    {
                        "coding": [
                            {
                                "system": "http://snomed.info/sct",
                                "code": "238995004",
                                "display": "Acneiform"
                            }
                        ]
                    },
                    {
                        "coding": [
                            {
                                "system": "http://snomed.info/sct",
                                "code": "56317004",
                                "display": "Alopecia"
                            }
                        ]
                    },
                    {
                        "coding": [
                            {
                                "system": "http://snomed.info/sct",
                                "code": "36715001",
                                "display": "Erythema multiforme"
                            }
                        ]
                    }
                ],
                "description": "Aspirin",
                "onset": "2022-06-25T09:00:00.000+08:00",
                "severity": "moderate",
                "exposureRoute": {
                    "coding": [
                        {
                            "system": "http://snomed.info/sct",
                            "code": "26643006",
                            "display": "Oral use"
                        }
                    ]
                },
                "note": [
                    {
                        "authorReference": {
                            "display": "Remark Author Practitioner Name"
                        },
                        "time": "2022-06-25T09:00:00.000+08:00",
                        "text": "Additional entry related to allergy reaction details"
                    }
                ]
            }
        ]
    }
API
Operation Address Request Method Example
Create Record [base]/AllergyIntolerance/@FacilityAllergyIdentifier PUT https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123
Update Record [base]/AllergyIntolerance/@FacilityAllergyIdentifier PUT https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123
Read Record [base]/AllergyIntolerance/@FacilityAllergyIdentifier GET https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123
Mapping
HIE Item Element Description Cardinality PHIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Profile Profile this resource claims to conform to 1..1 http://fhir.hie.moh.gov.my/StructureDefinition/AllergyIntolerance-my-core AllergyIntolerance.meta.profile Canonical
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Patient Who the sensitivity is for 1..1 Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|@phisMrnNo" AllergyIntolerance.patient.reference Reference
Encounter Encounter when the allergy or intolerance was asserted 0..1 Reference encounter record by "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|@phisMrnNo" AllergyIntolerance.encounter.reference Reference
Category Category of the identified substance 1..1 Allergen Type AllergyIntoleranceCategory AllergyIntolerance.category code
Active Ingredient Type of the substance/product, allergy or intolerance condition 1..1 Active Ingredient / Non Drug / Drug Allergy (Non MOH) ValueSetAllergyCode (MY Core) AllergyIntolerance.code.coding.code CodeableConcept
Formulary Whether or not the active ingredient is based on a formulary or not 1..1 Drug Allergy (Non MOH) AllergyIntolerance.extension.valueBoolean where AllergyIntolerance.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/formulary-boolean-my-core Boolean
Last Occurrence Date(/time) of last known occurrence of a reaction 0..1 AllergyIntolerance.lastOccurrence DateTime
Clinical Status The clinical status of the allergy or intolerance 1..1 AllergyIntoleranceClinicalStatusCodes AllergyIntolerance.clinicalStatus.coding.code CodeableConcept
Verification Status Assertion about certainty associated with the propensity, or potential risk, of a reaction to the identified substance (including pharmaceutical product) 1..1 Allergy Status AllergyIntoleranceVerificationStatusCodes AllergyIntolerance.verificationStatus.coding.code CodeableConcept
Recorded Date The recordedDate represents when this particular AllergyIntolerance record was created in the system, which is often a system-generated date 0..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 AllergyIntolerance.recordedDate DateTime
Last Updated When the resource version last changed 0..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 AllergyIntolerance.meta.lastUpdated DateTime (System Generated)
Recorder Who recorded the sensitivity 0..1 AllergyIntolerance.recorder.display String
Attester Source of the information about the allergy 0..1 AllergyIntolerance.asserter.display String
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Substance Codes defining the type of the substance (including pharmaceutical products) 0..1 Active Ingredient/Non Drug/Drug Allergy (Non MOH) ValueSetAllergyCode (MY Core) AllergyIntolerance.substance.coding.code CodeableConcept
Formulary Whether or not the substance is based on a formulary or not 1..1 AllergyIntolerance.reaction.extension.valueBoolean where AllergyIntolerance.reaction.extension.url=http://fhir.hie.moh.gov.my/StructureDefinition/formulary-boolean-my-core Boolean
Onset Date Date(/time) when manifestations showed 1..1 AllergyIntolerance.reaction.onset DateTime
Brand Name The brand name of the medication 0..1 AllergyIntolerance.reaction.description String
Severity Clinical assessment of the severity of the reaction event as a whole, potentially considering multiple different manifestations 0..1 AllergyIntoleranceSeverity AllergyIntolerance.reaction.severity CodeableConcept
Exposure Route Identification of the route by which the subject was exposed to the substance 0..1 SNOMEDCTRouteCodes AllergyIntolerance.reaction.exposureRoute.coding.code CodeableConcept
Reaction Adverse Reaction Events linked to exposure to substance 0..* Reaction Details ValueSetAllergyManifestation (MY Core) AllergyIntolerance.reaction.manifestation.coding.code CodeableConcept
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Reaction Note Text about event not captured in other fields 0..1 AllergyIntolerance.reaction.note.text String
Recorder Individual responsible for the annotation If Reaction Note exist 0..1, else 0..0 AllergyIntolerance.reaction.note.authorReference.display String
Recorded Date When the annotation was made If Reaction Note exist 0..1, else 0..0 AllergyIntolerance.reaction.note.time DateTime
Allergy Status

FHIR separates allergy status into clinical allergy.clinicalStatus and verification status.verificationStatus whereas PhIS only has 1 status field.
These are the agreed status mapping points between PhIS and HIE:

PhIS Status ClinicalStatus VerificationStatus
suspected active presumed
active active confirmed
unconfirmed resolved unconfirmed
Allergy Negation Statement

Scenario: PhIS will send allergy negation statements to HIE

Related Profile: AllergyIntoleranceNegation (MY Core)

Example JSON 
{
    "resourceType": "AllergyIntolerance",
    "id": "example-allergy-negation-phis",
    "meta": {
        "lastUpdated": "2022-08-17T10:24:11.265+08:00",
        "source": "http://phis.moh.gov.my",
        "profile": [
            "http://fhir.hie.moh.gov.my/StructureDefinition/AllergyIntolerance-negation-my-core"
        ]
    },
    "clinicalStatus": {
        "coding": [
            {
                "system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical",
                "code": "active",
                "display": "Active"
            }
        ]
    },
    "code": {
        "coding": [
            {
                "system": "http://snomed.info/sct",
                "code": "1631000175102",
                "display": "Require Allergy Assessment"
            }
        ]
    },
    "patient": {
        "reference": "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|PHIS-123"
    },
    "recordedDate": "2022-06-25T11:00:00.000+08:00",
    "recorder": {
        "display": "Recorder Practitioner Name"
    },
    "asserter": {
        "display": "Asserter Practitioner Name"
    }
}
API
Operation Address Request Method Example
Create Record [base]/AllergyIntolerance/@FacilityAllergyIdentifier PUT https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123
Update Record [base]/AllergyIntolerance/@FacilityAllergyIdentifier PUT https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123
Read Record [base]/AllergyIntolerance/@FacilityAllergyIdentifier GET https://fhir.hie.moh.gov.my/baseR4/AllergyIntolerance/HTJ-PHIS-Allergy-123
Mapping
HIE Item Element Description Cardinality PHIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Profile Profile this resource claims to conform to 1..1 http://fhir.hie.moh.gov.my/StructureDefinition/AllergyIntolerance-negation-my-core AllergyIntolerance.meta.profile Canonical
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Patient Who the negation statement is for 1..1 Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|@phisMrnNo" AllergyIntolerance.patient.reference Reference
Encounter Encounter when the allergy or intolerance was asserted 0..1 Reference encounter record by "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|@phisMrnNo" AllergyIntolerance.encounter.reference Reference
Negation Statement Type of the substance/product, allergy or intolerance condition 1..1 ValueSetAllergyNegation (MY Core) AllergyIntolerance.code.coding.code CodeableConcept
Clinical Status The clinical status of the allergy or intolerance 1..1 AllergyIntoleranceSeverity AllergyIntolerance.clinicalStatus.coding.code CodeableConcept
Recorded Date The recordedDate represents when this particular AllergyIntolerance record was created in the system, which is often a system-generated date 0..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 AllergyIntolerance.recordedDate DateTime
Recorder Who recorded this negation statement 0..1 AllergyIntolerance.recorder.display String
Attester who attested to this negation statement 0..1 AllergyIntolerance.asserter.display String

Composition

MTAC summary

Scenario: PhIS will send an MTAC summary to HIE.

Related Profile: Composition (MY Core)

Example JSON 
{
    "resourceType": "Composition",
    "id": "HTJ-PHIS-MTAC-123",
    "meta": {
        "source": "http://phis.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core"
        ]
    },
    "identifier": {
        "system": "http://fhir.hie.moh.gov.my/sid/composition-id",
        "value": "HTJ-PHIS-MTAC-123"
    },
    "status": "final",
    "type": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-type-my-core",
                "code": "34821-9",
                "display": "Pharmacology Note"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core",
                    "code": "LP173418-7",
                    "display": "Note"
                }
            ]
        }
    ],
    "confidentiality": "N",
    "subject": {
        "reference": "Patient/Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|PHIS-123"
    },
    "encounter": {
        "reference": "Encounter/Encounter?identifier=http://fhir.hie.moh.gov.my/sid/encounter-id|PHIS-ENC-2212000101"
    },
    "date": "2022-09-29T12:13:00+08:00",
    "author":  [
        {
            "display": "Recorder Practitioner Name"
        }
    ],
    "title": "Note",
    "custodian": {
        "reference": "Organization/11-05060009",
        "display": "HOSPITAL TUANKU JA'AFAR"
    },
    "event":  [
        {
            "code":  [
                {
                    "coding":  [
                        {
                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core",
                            "code": "0002-0001",
                            "display": "MTAC (Medical therapy adherance clinic)"
                        }
                    ]
                }
            ],
            "period": {
                "start": "2022-09-29T12:13:00+08:00"
            }
        }
    ],
    "section":  [
        {
            "title": "Clinical Information",
            "code": {
                "coding":  [
                    {
                        "system": "http://loinc.org",
                        "code": "55752-0",
                        "display": "Clinical Information"
                    }
                ]
            },
            "text": {
                "status": "generated",
                "div": " <div xmlns=\"http://www.w3.org/1999/xhtml\"> <p> <b>1. Facility Information</b> </p> <p>Facility name &amp; ID: (Remarks) </p><br/> <p> <b>2. Patient Information</b> </p> <p>Patient identification: (Remarks) </p> <p><br/> <b>3. MTAC Order</b> </p> <p>Virtual Session: (Remarks)</p> <p>Type of MTAC: (Remarks)</p> <p>Appointment Date: (Remarks)</p> <p>Appointment Type: (Remarks) </p> <p><br/> <b>4. MTAC Reporting</b> </p> <p>Understanding: (Remarks)</p> <p>MTAC Status: (Remarks) </p></div>"
            }
        }
    ]
}
API
Operation Address Request Method Example
Create Record [base]/Composition/@FacilityCompositionIdentifier PUT https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MTAC-123
Update Record [base]/Composition/@FacilityCompositionIdentifier PUT https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MTAC-123
Read Record [base]/Composition/@FacilityCompositionIdentifier GET https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MTAC-123
Mapping
HIE Item Element Description Cardinality PHIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Profile Profile this resource claims to conform to 1..1 http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core Composition.meta.profile Canonical
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Category Classification of the clinical document at a macro level 1..1 ValueSetCompositionCategory (MY Core) Composition.category.coding.code=LP173418-7 CodeableConcept
Type Type of composition 1..1 ValueSetCompositionType (MY Core) Composition.type.coding.code=34821-9 CodeableConcept
Event The clinical service(s) being documented 1..1 ValueSetCompositionEvent (MY Core) Composition.event.coding.code=0002-0001 CodeableConcept
Status The workflow/clinical status of the composition 1..1 CompositionStatus Composition.status CodeableConcept
Subject Who and/or what the composition is about 1..1 Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|@phisMrnNo" Composition.subject.reference Reference
Encounter The clinical encounter or type of care this documentation is associated with 0..1 Reference encounter record by "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|@phisMrnNo" Composition.encounter.reference Reference
Recorder Date Composition editing time 1..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 Composition.date DateTime
Event Date The period covered by the documentation 0..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 Composition.event.period.start DateTime
Recorder Who and/or what authored the composition 0..1 Composition.author.display String
Facility Organization which maintains the composition 0..1 Reference facility related by "Organization/@OrganizationPikId" Composition.custodian.reference Reference
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Section The root of the sections that make up the composition. 1..1 Hardcode as 55752-0 (Clinical Information) from http://loinc.org Composition.section.code.coding.code CodeableConcept
Entry Text summary of the section, for human interpretation 1..1 Refer sample JSON for MTAC content Composition.section.text.div where Composition.section.code.coding.code=55752-0 HTML entry field
MC summary

Scenario: PhIS will send MC summary to HIE

Related Profile: Composition (MY Core)

Example JSON 
{
    "resourceType": "Composition",
    "id": "HTJ-PHIS-MC-123",
    "meta": {
        "source": "http://phis.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core"
        ]
    },
    "identifier": {
        "system": "http://fhir.hie.moh.gov.my/sid/composition-id",
        "value": "HTJ-PHIS-MC-123"
    },
    "status": "final",
    "type": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-type-my-core",
                "code": "34821-9",
                "display": "Pharmacology Note"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core",
                    "code": "LP173418-7",
                    "display": "Note"
                }
            ]
        }
    ],
    "confidentiality": "N",
    "subject": {
        "reference": "Patient/Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|PHIS-123"
    },
    "encounter": {
        "reference": "Encounter/Encounter?identifier=http://fhir.hie.moh.gov.my/sid/encounter-id|PHIS-ENC-2212000101"
    },
    "date": "2022-09-29T12:13:00+08:00",
    "author":  [
        {
            "display": "Recorder Practitioner Name"
        }
    ],
    "title": "Note",
    "custodian": {
        "reference": "Organization/11-05060009",
        "display": "HOSPITAL TUANKU JA'AFAR"
    },
    "event":  [
        {
            "code":  [
                {
                    "coding":  [
                        {
                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core",
                            "code": "0002-0002",
                            "display": "MC (Medication Counselling)"
                        }
                    ]
                }
            ],
            "period": {
                "start": "2022-09-29T12:13:00+08:00"
            }
        }
    ],
    "section":  [
        {
            "title": "Clinical Information",
            "code": {
                "coding":  [
                    {
                        "system": "http://loinc.org",
                        "code": "55752-0",
                        "display": "Clinical Information"
                    }
                ]
            },
            "text": {
                "status": "generated",
                "div": " <div xmlns=\"http://www.w3.org/1999/xhtml\"> <p> <b>1. Facility Information</b> </p> <p>Facility name &amp; ID: (Remarks) </p> <br /> <p> <b>2. Patient Information</b> </p> <p>Patient identification: (Remarks) </p> <br /> <p> <b>3. Individual Medication Counseling (Medication Counseling Order)</b> </p> <p>Virtual Session: (Remarks)</p> <p>Appointment Date: (Remarks)</p> <p>Appointment Type: (Remarks)</p> <p>Counselling Type: (Remarks) </p> <p>HMR Type: (Remarks) </p> <p>Counselling Topics: (Remarks) </p> <p>Counselling Sub-topic: (Remarks) </p> <br /> <p> <b>4. Medication Counseling Reporting</b> </p> <p>Understanding: (Remarks)</p> <p>Follow up required: (Remarks) </p></div>"
            }
        }
    ]
}
API
Operation Address Request Method Example
Create Record [base]/Composition/@FacilityCompositionIdentifier PUT https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MC-123
Update Record [base]/Composition/@FacilityCompositionIdentifier PUT https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MC-123
Read Record [base]/Composition/@FacilityCompositionIdentifier GET https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-MC-123
Mapping
HIE Item Element Description Cardinality PHIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Profile Profile this resource claims to conform to 1..1 http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core Composition.meta.profile Canonical
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Category Classification of clinical document at a macro level 1..1 ValueSetCompositionCategory (MY Core) Composition.category.coding.code=LP173418-7 CodeableConcept
Type Type of composition 1..1 ValueSetCompositionType (MY Core) Composition.type.coding.code=34821-9 CodeableConcept
Event The clinical service(s) being documented 1..1 ValueSetCompositionEvent (MY Core) Composition.event.coding.code=0002-0002 CodeableConcept
Status The workflow/clinical status of the composition 1..1 CompositionStatus Composition.status CodeableConcept
Subject Who and/or what the composition is about 1..1 Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|@phisMrnNo" Composition.subject.reference Reference
Encounter The clinical encounter or type of care this documentation is associated with 0..1 Reference encounter record by "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|@phisMrnNo" Composition.encounter.reference Reference
Recorder Date Composition editing time 1..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 Composition.date DateTime
Event Date The period covered by the documentation 0..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 Composition.event.period.start DateTime
Recorder Who and/or what authored the composition 0..1 Composition.author.display String
Facility Organization which maintains the composition 0..1 Reference facility related by "Organization/@OrganizationPikId" Composition.custodian.reference Reference
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Section The root of the sections that make up the composition 1..1 Hardcode as 55752-0 (Clinical Information) from http://loinc.org Composition.section.code.coding.code CodeableConcept
Entry Text summary of the section, for human interpretation 1..1 Refer sample JSON for MTAC content Composition.section.text.div where Composition.section.code.coding.code=55752-0 HTML entry field
ADR report

Scenario: PhIS will send ADR report to HIE

Related Profile: Composition (MY Core)

Example JSON 
{
    "resourceType": "Composition",
    "id": "HTJ-PHIS-ADR-123",
    "meta": {
        "source": "http://phis.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core"
        ]
    },
    "identifier": {
        "system": "http://fhir.hie.moh.gov.my/sid/composition-id",
        "value": "HTJ-PHIS-ADR-123"
    },
    "status": "final",
    "type": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-type-my-core",
                "code": "34821-9",
                "display": "Pharmacology Note"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core",
                    "code": "LP173418-7",
                    "display": "Note"
                }
            ]
        }
    ],
    "confidentiality": "N",
    "subject": {
        "reference": "Patient/Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|PHIS-123"
    },
    "encounter": {
        "reference": "Encounter/Encounter?identifier=http://fhir.hie.moh.gov.my/sid/encounter-id|PHIS-ENC-2212000101"
    },
    "date": "2022-09-29T12:13:00+08:00",
    "author":  [
        {
            "display": "Recorder Practitioner Name"
        }
    ],
    "title": "Note",
    "custodian": {
        "reference": "Organization/11-05060009",
        "display": "HOSPITAL TUANKU JA'AFAR"
    },
    "event":  [
        {
            "code":  [
                {
                    "coding":  [
                        {
                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core",
                            "code": "0002-0003",
                            "display": "ADR (Adverse Drug Event)"
                        }
                    ]
                }
            ],
            "period": {
                "start": "2022-09-29T12:13:00+08:00"
            }
        }
    ],
    "section":  [
        {
            "title": "Clinical Information",
            "code": {
                "coding":  [
                    {
                        "system": "http://loinc.org",
                        "code": "55752-0",
                        "display": "Clinical Information"
                    }
                ]
            },
            "text": {
                "status": "generated",
                "div": " <div xmlns=\"http://www.w3.org/1999/xhtml\"> <p> <b>1. Facility Information</b> </p> <p>Facility name &amp; ID: (Remarks) </p><br/> <p> <b>2. Patient Information</b> </p> <p>Patient identification: (Remarks) </p><br/> <p> <b>3. Adverse Reaction Description</b> </p> <p>a) Adverse Reaction Description: (Remarks)</p> <p>b) Time to Onset of Reaction (1): (Remarks)</p> <p>b) Time to Onset of Reaction (2): (Remarks)</p> <p>c) Reaction subsided after action taken with suspected drug: (Remarks) </p> <p>d) Reaction reappeared after reintroducing suspected drug: (Remarks) </p> <p>e) Outcome (Remarks) </p><br/> <p> <b>4. Suspected Drug</b> </p> <p>MDC: (Remarks)</p> <p>Product/Generic Name: (Remarks)</p> <p>Drug Type: (Remarks)</p> <p>Dose: (Remarks)</p> <p>Route: (Remarks)</p> <p>Manufacturer: (Remarks)</p> <p>Product Reg No.: (Remarks)</p> <p>Brand: (Remarks)</p> <p>Therapy Start Date: (Remarks)</p> <p>Therapy End Date: (Remarks)</p> <p>Therapy End Date Remark: (Remarks)</p> <p>Indication: (Remarks)</p></div>"
            }
        }
    ]
}
API
Operation Address Request Method Example
Create Record [base]/Encounter/@FacilityRnIdentifier PUT https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-ADR-123
Update Record [base]/Encounter/@FacilityRnIdentifier PUT https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-ADR-123
Read Record [base]/Encounter/@FacilityRnIdentifier GET https://fhir.hie.moh.gov.my/baseR4/Composition/HTJ-PHIS-ADR-123
Mapping
HIE Item Element Description Cardinality PHIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Profile Profile this resource claims to conform to 1..1 http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core Composition.meta.profile Canonical
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Category Classification of the clinical document at a macro level 1..1 ValueSetCompositionCategory (MY Core) Composition.category.coding.code=LP173418-7 CodeableConcept
Type Type of composition 1..1 ValueSetCompositionType (MY Core) Composition.type.coding.code=34821-9 CodeableConcept
Event The clinical service(s) being documented 1..1 ValueSetCompositionEvent (MY Core) Composition.event.code.coding.code=0002-0003 CodeableConcept
Status The workflow/clinical status of the composition 1..1 CompositionStatus Composition.event.code.coding.code CodeableConcept
Subject Who and/or what the composition is about 1..1 Reference patient record by "Patient?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|@phisMrnNo" Composition.subject.reference Reference
Encounter The clinical encounter or type of care this documentation is associated with 0..1 Reference encounter record by "Encounter?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|@phisMrnNo" Composition.encounter.reference Reference
Recorder Date Composition editing time 1..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 Composition.date DateTime
Event Date The period covered by the documentation 0..1 FHIR Format YYYY-MM-DDThh:mm:ss+08:00 Composition.event.period.start DateTime
Recorder Who and/or what authored the composition 0..1 Composition.author.display String
Facility Organization which maintains the composition 0..1 Reference facility related by "Organization/@OrganizationPikId" Composition.custodian.reference Reference
HIE Item Element Description Cardinality PhIS Field Name ValueSet/Remark FHIR Element FHIR Element DataType
Section The root of the sections that make up the composition 1..1 Hardcode as 55752-0 (Clinical Information) from http://loinc.org Composition.section.code.coding.code CodeableConcept
Entry Text summary of the section, for human interpretation 1..1 Refer sample JSON for MTAC content Composition.section.text.div where Composition.section.code.coding.code=55752-0 HTML entry field

MedicationKnowledge

Scenario: HIE will retrieve Master Drug List from PhIS IWP API.

Related Profile: MedicationKnowledge (MY Core)

Example JSON 
{
    "resourceType": "MedicationKnowledge",
    "id": "N02BE01000T1001XX",
    "meta": {
        "source": "http://provider.hie.moh.gov.my",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/MedicationKnowledge-my-core"
        ]
    },
    "extension":  [
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core",
            "extension":  [
                {
                    "url": "recorder",
                    "valueReference": {
                        "display": "Recorder Practitioner name"
                    }
                },
                {
                    "url": "recordedDate",
                    "valueDateTime": "2022-08-15T14:48:27+08:00"
                },
                {
                    "url": "lastUpdater",
                    "valueReference": {
                        "display": "Last updater Practitioner name"
                    }
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "N02BE01000T1001XX",
                "display": "Paracetamol 500 mg Tablet"
            }
        ],
        "text": "Paracetamol 500mg Tab"
    },
    "status": "active",
    "doseForm": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-dose-form-my-core",
                "code": "270",
                "display": "Oral Tablet"
            }
        ]
    },
    "synonym":  [
        "N/A"
    ],
    "productType":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-type-my-core",
                    "code": "PN",
                    "display": "PN"
                }
            ]
        }
    ],
    "ingredient":  [
        {
            "itemCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/active-ingredient-my-core",
                        "code": "410",
                        "display": "Amino acid+ dextrose+ lipid+ electrolytes"
                    }
                ],
                "text": "Amino acid+ dextrose+ lipid+ electrolytes"
            },
            "strength": {
                "numerator": {
                    "value": 500,
                    "unit": "mg",
                    "system": "http://unitsofmeasure.org",
                    "code": "mg"
                },
                "denominator": {
                    "value": 1,
                    "unit": "tablet",
                    "system": "http://unitsofmeasure.org",
                    "code": "tablet"
                }
            }
        }
    ],
    "administrationGuidelines":  [
        {
            "dosage":  [
                {
                    "type": {
                        "coding":  [
                            {
                                "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-sub-group-my-core",
                                "code": "70",
                                "display": "Parenteral Nutrition"
                            }
                        ]
                    },
                    "dosage":  [
                        {
                            "additionalInstruction":  [
                                {
                                    "coding":  [
                                        {
                                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-special-instruction-my-core",
                                            "code": "10",
                                            "display": "Administer 15-30 minutes before _____"
                                        }
                                    ],
                                    "text": "Administer 15-30 minutes before _____"
                                },
                                {
                                    "coding":  [
                                        {
                                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-cautionary-my-core",
                                            "code": "60",
                                            "display": "Avoid contact with eyes"
                                        }
                                    ],
                                    "text": "Avoid contact with eyes"
                                }
                            ],
                            "patientInstruction": "Apply as directed",
                            "timing": {
                                "code": {
                                    "coding":  [
                                        {
                                            "system": "http://terminology.hl7.org/CodeSystem/v3-GTSAbbreviation",
                                            "code": "BID",
                                            "display": "BID"
                                        }
                                    ]
                                }
                            },
                            "route": {
                                "coding":  [
                                    {
                                        "system": "http://snomed.info/sct",
                                        "code": "26643006",
                                        "display": "Oral route"
                                    }
                                ]
                            },
                            "doseAndRate":  [
                                {
                                    "doseQuantity": {
                                        "value": 500,
                                        "unit": "mg",
                                        "system": "http://unitsofmeasure.org",
                                        "code": "mg"
                                    }
                                }
                            ]
                        }
                    ]
                }
            ]
        }
    ],
    "medicineClassification":  [
        {
            "extension":  [
                {
                    "url": "http://fhir.hie.moh.gov.my/StructureDefinition/formulary-boolean-my-core",
                    "valueBoolean": true
                }
            ],
            "type": {
                "coding":  [
                    {
                        "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-sub-group-my-core",
                        "code": "70",
                        "display": "Parenteral Nutrition"
                    }
                ]
            },
            "classification":  [
                {
                    "coding":  [
                        {
                            "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-category-my-core",
                            "code": "B",
                            "display": "B"
                        }
                    ]
                }
            ]
        }
    ],
    "regulatory":  [
        {
            "regulatoryAuthority": {
                "display": "placeholder"
            },
            "schedule":  [
                {
                    "schedule": {
                        "coding":  [
                            {
                                "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-schedule-my-core",
                                "code": "SP",
                                "display": "Schedule Poison"
                            }
                        ]
                    }
                }
            ]
        }
    ]
}

Medication

Scenario: HIE will retrieve Master Drug List from PhIS IWP API to build the Facility Drug List.

Related Profile: Medication (MY Core)

Example JSON 
{
    "resourceType": "Medication",
    "id": "example-medication",
    "meta": {
        "versionId": "10",
        "lastUpdated": "2022-08-22T08:29:46.670+08:00",
        "source": "http://provider.hie.moh.gov.my#luMHDWniHDEi418A",
        "profile":  [
            "http://fhir.hie.moh.gov.my/StructureDefinition/Medication-my-core"
        ]
    },
    "extension":  [
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core",
            "extension":  [
                {
                    "url": "recorder",
                    "valueReference": {
                        "reference": "PractitionerRole/8c99c924-ba17-47aa-8bf1-b88cf0e68b61/_history/1",
                        "display": "HASAN"
                    }
                },
                {
                    "url": "recordedDate",
                    "valueDateTime": "2022-08-15T14:48:27+08:00"
                },
                {
                    "url": "lastUpdater",
                    "valueReference": {
                        "reference": "HASAN",
                        "display": "PractitionerRole/8c99c924-ba17-47aa-8bf1-b88cf0e68b61/_history/1"
                    }
                }
            ]
        },
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/service-provider-my-core",
            "valueReference": {
                "reference": "Organization/11-05060009"
            }
        },
        {
            "url": "http://fhir.hie.moh.gov.my/StructureDefinition/medication-knowledge-my-core",
            "valueReference": {
                "reference": "MedicationKnowledge/N02BE01000T1001XX"
            }
        }
    ],
    "code": {
        "coding":  [
            {
                "system": "http://fhir.hie.moh.gov.my/CodeSystem/drug-my-core",
                "code": "N02BE01000T1001XX",
                "display": "Paracetamol 500 mg Tablet"
            }
        ],
        "text": "Paracetamol 500mg Tab"
    },
    "status": "active"
}