HL7 FHIR® Implementation Guide: Ophthalmology Retinal, Release 1
0.1.0 - STU 1 Ballot

HL7 FHIR® Implementation Guide: Ophthalmology Retinal, Release 1, published by HL7 International - Patient Care WG. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/fhir-eyecare-ig/ and changes regularly. See the Directory of published versions

## Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

### Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide

OCT macula Diagnostic Report | The DiagnosticReport profile for an OCT macula
OCT RNFL Diagnostic Report | The DiagnosticReport profile for an OCT RNFL
OCT RFNL Observations | The Observations associated with the OCT RNFL DiagnosticReport (note: this valueset can also be used independently to describe specific findings/Observations captured by a OCT test, which may not necessarily be referenced by the DiagnosticReport.)
Intraocular Pressure (IOP) | A measurement of a patient’s intraocular (within the eyeball) pressure (in mmHg).
OCT macula Observations | The Observations associated with the OCT macula DiagnosticReport (note: this valueset can also be used independently to describe specific findings/Observations captured by a OCT test, which may not necessarily be referenced by the DiagnosticReport.)
Opththalmic Procedure | A profile indicating that an active ophthlmic intervention is or was performed on or for a patient. The ‘Ocular anatomical location’ profile should be used together with this profile.
Ocular anatomical location | The description of an ophthalmic anatomical site that is located within the following structures: the eyeball or the periocular or orbital regions (as opposed to non-ocular anatomical locations). This profile is used by combining the unique valueset (hyperlink) for relevant ophthalmic specific BodyStructure.locationQualifier (Body Site modifier) in combination with the base Observation BodyStructure.location (Body Site; descendants from SNOMED 371398005 (Eye Region Structure), each with a preferred binding in order to refine the accuracy of the location decription of occular structures. This unique qualifying element is important because these locations are routinely described either diffently and/or more granularly than other body parts. Of note - non occular (or surrounding) anatomical location references of Observations (eg - arm) do not need to use this modified specialty profile.
Visual Acuity (VA) | An assessment of a patients ability to see.
Ophthalmic diagnostic test report | Base profile specifically constrained for describing ophthalmic reports
Base ophthalmic Observation profile | Base profile specifically constrained for describing ophthalmic Observations
VF Diagnostic Report | The DiagnosticReport profile for a visual field DT
Ophthalmic Diagnoses | A profile to describe the formal past/present clinical diagnosis of a specific non-ophthalmic pathological Condition. As noted above, although the Condition Resource is also referenced in the non-ophthalmic findings profile, this profile is a modification of the base Condition Resource (as opposed to a base Obervation Resource modification, referencing Condition).
VF Observations | The Observations associated with the VF DiagnosticReport (note: this valueset can also be used independently to describe specific findings/Observations captured by a VF test, which may not necessarily be referenced by the DiagnosticReport.)
Other ophthalmic clinical Observation | Observations made during an ophthalmic clinical examination that relate to ocular structures (and hence should use the ““ocular anatomic location”” profile). Although the Condition resource is used in this profile (with the preferred binding of a specific ophthalmic valueset), this does not intend to indicate that a definitive clinical diagnosis has been made. Rather, that a certain finding has been observed. Observations made during a clinical examination which may or may not be related to the routine ophthalmic examination, but describes findings that are not necessarily related to the ocular, periocular or orbital anatomical location or pathology (and hence is unlikely to requre the use of the “ocular anatomic profile”).

### Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide

Ophthalmic anatomical location qualifiers | Describes whether a recorded observation is either final or amended
Ophthalmology Condition ICD10 and SNOMED codes ValueSet | Clinical findings for the eye region.
OCT Macula Observable Entities ValueSet | OCT Macula observations coding
Observation Status | Describes whether a recorded observation is either final or amended
Intraocular pressure (IOP) method valueset | Describes the various methods of capturing IOP that relate to the IOP Observation profile
Ophthalmology Procedures Valueset | This ValueSet represents procedure codes for clinical and billing purposes.
Visual acuity chart valueset (SNOMED) | Describes the various charts that can be used to assess visual acuity where concept descends from 400912000 (Visual acuity test equipment (physical object))
Visual Field Observable Entities ValueSet | Visual field observation coding
Ophthalmology observations (SNOMED) | Concept descends from 363926002 - Eye/vision observable (observable entity)
OCT RNFL Observable Entities ValueSet | OCT RNFL observations coding
Ophthalmic anatomical location | Describes the ophthalmic structure being referenced
Visual acuity method valueset (SNOMED) | Describes the visual acuity observation result, where concept descends from 363983007 (Visual acuity)

### Terminology: Code Systems

These define new code systems used by systems conforming to this implementation guide

Visual field test parameter observations | Visual field observation additional codes
IOP Methods Code System | IOP additional method types
Body Structure Qualifiers | Additional body site qualifiers

### Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like

Right Eye Body Structure
Left Eye Body Structure
Practitioner Example
Patient Example
Media Example
Media Example
Example Observation - va-snellen-distance-re-0
Example DiagnosticReport - diagnostic-report-visual-field-test-re-0
Example Observation - observation-iop-icare-home-le-0
Example Observation - vf-fixation-loss-re-0
Example Observation - va-snellen-best-corrected-re-0
Example Observation - vf-false-positives-re-0
Example Observation - vf-false-positives-le-0
Example DiagnosticReport - diagnostic-report-visual-field-test-le-0
Example Observation - vf-pattern-standard-deviation-le-0
Example Observation - observation-refraction-re-0
Example Observation - vf-pattern-standard-deviation-re-0
Example Observation - vf-test-duration-le-0
Example Observation - va-snellen-corrected-le-0
Example Observation - observation-refraction-le-0
Example Observation - vf-fixation-loss-le-0
Example Condition - condition-ophthal-glaucoma
Example Observation - vf-mean-deviation-re-0
Example Observation - vf-test-duration-re-0
Example Observation - va-snellen-best-corrected-le-0
Example Observation - observation-iop-icare-home-re-0
Example Observation - va-snellen-corrected-re-0
Example Observation - observation-iop-goldman-le-0
Example Procedure - perimetry-24-2-perimetry-test
Example Observation - observation-iop-goldman-re-0
Example Observation - vf-mean-deviation-le-0
Example Observation - va-snellen-distance-le-0