# 身體活動實施指南-運動處方情境
Source:https://build.fhir.org/ig/HL7/physical-activity/scenarios.html#exercise-prescription
1.2.1 Exercise Prescription 運動處方
---
> Mr. Khatun is a 55-year-old male weighing 190 pounds, with a height of 5' 6". This gives him a body-mass index just over 30. At his annual physical exam, his clinician Dr. Patel notes that this, combined with his high blood pressure puts him at increased risk for heart attack. He reviews the results of the electronic intake survey Mr. Khatun had completed and notes that his physical activity vital sign showed an average of only 20 minutes per week of moderate to vigorous physical activity and negligible strength-based activity and asked him more about his activity levels.
Khatun 是一名55歲的男性，體重約86公斤，身高約167.6公分，BMI略高於30。Patel 醫生在他的年度健檢中注意到這一點，再加上考慮到他的高血壓問題，將他列在心臟病高危險群中。醫生看了 Khatun 的初診問卷，注意到他每週只進行約20分鐘的中等至劇烈運動，並且無重訓。所以醫生進一步詢問 Khatun 關於更多他的活動水平細節。
> Mr. Khatun indicates that, since his children had gotten older, he has less incentive to be outside and doing things, and that his job is largely sedentary. Dr. Patel explains that Mr. Khatun's activity levels are far below the weekly target to maintain good health and that increasing his physical activity levels, plus some adjustments to his diet, could improve his weight, lower his blood pressure, as well help him to feel more energetic.
Khatun 說自從他的孩子們長大後，他就沒有了外出的動力，而且他的工作基本上是久坐不動的。醫生解釋，Khatun 的活動水平遠低於維持良好健康的每週目標，所以他建議透過增加身體活動水平和調整飲食，這有助於 Khatun 減重並降血壓，同時也能使他感覺更有活力。
> The two of them spend a few minutes discussing activities Mr. Khatun had enjoyed in the past and how he might increase his physical activity level without his children to drive that behavior. Dr. Patel captures those ideas in his notes. The two of them agree to schedule their next visit in 6 months and that by then, Mr. Khatun would aim to be doing at least 100 minutes of moderate to vigorous exercise per week. At the conclusion of his visit, Mr. Khatun receives a brochure with a QR-code link to an app he can use to track his physical activity. Dr. Patel also provides him a formal prescription for exercise, indicating "This prescription is as important as any medication or lab test, only this one can be free - and even fun."
他們兩個花了幾分鐘的時間討論Khatun過去喜歡的活動，以及如何在沒有孩子作為動力的情況下，提高他的身體活動水平。他們將下一次回診訂在半年後，在這期間 Khatun 每週要進行至少100分鐘的中等至劇烈運動。在最後，Khatun 收到了一份帶有 QR Code 的小手冊，掃描後手機畫面可以跳轉到一個可以用來追蹤他的身體活動的 App。Patel 醫生還為他開了一份運動處方，上面寫：「該處方跟任何藥物或實驗一樣重要，只不過這是免費的 —— 還能帶來樂趣。」
> At home, Mr. Khatun downloads and installs the app and, after logging in with the email address he'd given the clinic receptionist, he sees that the plan and target exercise level, as well as a copy of his "exercise prescription" have automatically been downloaded into the app. Over the course of the next 6 months, he tracks his exercise levels which are stored in an app-specific personal health record (PHR). Heart rate and step counts are automatically propagated from his phone. Mr. Khatun opts to allow the high-level summary information to flow to Dr. Patel's electronic health record (EHR). By the time he returns to the clinic for his 6-month touchpoint, the doctor can see in his EHR that Mr. Khatun has not only met, but exceeded his goal. The doctor congratulates him on his progress, the fact he's lost 10 pounds, and that his blood pressure is starting to come down. They set to work adjusting his plan and set a new target, this time for Mr. Khatun to reach the guideline target of 150 minutes/week.
Khatun 回到家後下載了 App，並用他之前給診所櫃檯的 Email 登入，他看到計畫和目標運動水平，以及已自動下載的運動處方副本。在接下來的六個月內，他要記錄自己的運動水平，這些生理數據會儲存在 App 的個人健康記錄（Personal Health Record，PHR）中，心率和步數則是可以從他的手機自動同步。Khatun 也開放權限允許將進階摘要數據傳到 Patel 醫生的電子健康記錄（Electronic Health Record，EHR）中。六個月後 Khatun 回診檢查，醫生可以在他的 EHR 中看到，Khatun 不僅達到了目標，甚至遠比想像中更好，Khatun 不僅減掉了4.5公斤，血壓也開始下降了。接下來，醫生為 Khatun 訂了新目標，讓他接下來每週運動150分鐘。
1.2.1.1 How this IG applies 如何應用實施指南
---
> Mr. Khatun's app performed a search operation on the EHR's FHIR endpoint to retrieve CarePlan, Goal and ServiceRequest resources that complied with the exercise plan, goal, and exercise prescription profiles defined in this guide. In all three cases, the search parameters included Mr. Khatun's Patient.id as determined by the log-in process as well as a category filter retrieving only those plans, goals and orders related to "physical activity".
Khatun 的 App 在 EHR 的 FHIR 端執行了一個[查詢](https://hl7.org/fhir/R4/search.html)操作，以取得CarePlan、Goal 和 ServiceRequest 資源，因為這三者符合本指南定義的[運動計劃](https://build.fhir.org/ig/HL7/physical-activity/StructureDefinition-pa-careplan.html)、[目標](https://build.fhir.org/ig/HL7/physical-activity/StructureDefinition-pa-goal.html)和[運動處方](https://build.fhir.org/ig/HL7/physical-activity/StructureDefinition-pa-servicerequest.html) [Profiles](#Profile)，他們的搜尋參數包含了 Khatun 的 Patient.id（從登入流程得到），以及一個類別過濾器，僅用來搜尋與「身體活動」相關的計劃、目標和指令。
> The exercise levels and supporting information captured by Mr. Khatun's app were propagated to the app's PHR storage system using the create operation with the Days-per-week, Minutes-per-day, Minutes-per-week, and Strength Days-per-week profiles, as well as with the Time-based observation profile and the constraints established for heart rate and step count measures in the Time-based measures section of this implementation guide.
App 會把接收到的運動水平及其相關數據傳送到 PHR 儲存，再透過以下 profiles [建立](https://hl7.org/fhir/R4/http.html#create)新的資源:
* [每週中度至劇烈運動的天數(Days-per-week)](https://build.fhir.org/ig/HL7/physical-activity/StructureDefinition-pa-observation-evs-days-per-week.html)
* [每天中度至劇烈運動的分鐘數(Minutes-per-day)](https://build.fhir.org/ig/HL7/physical-activity/StructureDefinition-pa-observation-evs-min-per-day.html)
* [每週中度至劇烈運動的分鐘數(Minutes-per-week)](https://build.fhir.org/ig/HL7/physical-activity/StructureDefinition-pa-observation-evs-min-per-week.html)
* [每週重訓的天數(Strength Days-per-week)](https://build.fhir.org/ig/HL7/physical-activity/StructureDefinition-pa-observation-strength-days-per-week.html)
* [時基觀察(Time-based observation)](https://build.fhir.org/ig/HL7/physical-activity/StructureDefinition-pa-observation-time-measure.html)
並用本指南中的[時基量測](https://build.fhir.org/ig/HL7/physical-activity/measures.html#time-based-measures)所得到的心率跟步數設立限制。
> While the clinician opted not to receive the daily heart rate and exercise log information, his EHR did receive the base measures defined in this IG, including the physical activity vital signs. These Observations were transmitted to the EHR with a create operation using the Days-per-week, Minutes-per-day, Minutes-per-week, and Strength Days-per-week.
雖然醫師選擇不每天接收心率和運動日誌，但他的 EHR 確實接收了本實施指南中定義的[基礎量測](https://build.fhir.org/ig/HL7/physical-activity/measures.html#base)，包括身體活動生命徵象。這些數據會傳送到 EHR 並透過[每週中度至劇烈運動的天數(Days-per-week)](https://build.fhir.org/ig/HL7/physical-activity/StructureDefinition-pa-observation-evs-days-per-week.html)、[每天中度至劇烈運動的分鐘數(Minutes-per-day)](https://build.fhir.org/ig/HL7/physical-activity/StructureDefinition-pa-observation-evs-min-per-day.html)、[每週中度至劇烈運動的分鐘數(Minutes-per-week)](https://build.fhir.org/ig/HL7/physical-activity/StructureDefinition-pa-observation-evs-min-per-week.html)跟[每週重訓的天數(Strength Days-per-week)](https://build.fhir.org/ig/HL7/physical-activity/StructureDefinition-pa-observation-strength-days-per-week.html)[建立](https://hl7.org/fhir/R4/http.html#create)資源。
> A technical representation of this scenario, showing the different systems, the interactions between them and example instances showing the queries and payloads involved can be found on the Example Scenario 1 page.
該情境的技術呈現，展示了在不同系統之間的互動，以及查詢和負載的實例(見[範例情境1](https://build.fhir.org/ig/HL7/physical-activity/ExampleScenario-Scen1ExercisePrescriptionScenario.html))。
1.2.1.2 Alternatives 替代方案
---
> * The clinician could also have opted to receive the more frequent supporting measures as well.
* 臨床醫師也可以選擇更頻繁接收[輔助量測(supporting measures)](https://build.fhir.org/ig/HL7/physical-activity/measures.html#support)。
> * Rather than having a copy of the base and supporting measures created in his EHR, Dr. Patel's EHR could have performed a search operation on the personal health record backing Mr. Khatun's app and viewed his exercise Observations that way.
* Patel 醫生的 EHR 可以在 Khatun 的 App 裡的 PHR 中執行[搜尋](https://hl7.org/fhir/R4/search.html)並藉此瀏覽他的運動數據，而不是在 EHR 中建立數據副本。
> * Instead of storing Mr. Khatun's exercise information in a personal health record, the app could have been configured to store the information in Dr. Patel's EHR directly.
* App 可以設定直接將數據儲存在醫生的 EHR，而不是存在 App 裡的 PHR。
> * If Dr. Patel's EHR had granted the necessary permissions, Mr. Khatun could have updated his goals or created a new one once it became evident that he was up for more of a challenge.
* 如果醫生的 EHR 已被授予必要權限，一旦 Khatun 很明顯可以迎接更進階的運動挑戰，他可以直接[更新](https://hl7.org/fhir/R4/http.html#update)或[建立](https://hl7.org/fhir/R4/http.html#create)新目標。
1.2.1.3 Where other specifications may fit 其他規格可能適用的地方
---
> * The initial screening form Mr. Khatun completed may have been expressed as an SDC Questionnaire, and the completed form as a QuestionnaireResponse.
* Khatun 完成的初診測試表格可能表現為[SDC](https://hl7.org/fhir/uv/sdc/STU3/index.html)問卷，已填寫完成的表格則為[問卷回應（QuestionnaireResponse）](https://www.hl7.org/fhir/questionnaireresponse-definitions.html)
> * The authentication process of Mr. Khatun is likely managed through the SMART on FHIR authorization process.
* Khatun 的認證過程可能透過 [SMART on FHIR 授權過程管理](https://hl7.org/fhir/smart-app-launch/app-launch.html)
> Note: In managing physical activity issues, it is important to consider social determinants of health (SDOH) that can significantly impact a person's ability to engage in physical activity. Factors such as access to safe environments, socioeconomic status, and community resources play a crucial role in promoting and sustaining physical activity levels.
注意：在管理身體活動問題時，考慮社會決定因素（Social Determinants Of Health，SDOH）是很重要的，因為這可能十分影響個人參與身體活動的能力。其他因素像是安全環境的可及性、社經地位和社區資源等，在促進和維持身體活動水平方面也是扮演著關鍵角色。
Comment
---
##### [Profile](https://www.hl7.org/fhir/profiling.html#glossary)
* Description: A set of constraints on a resource represented as a structure definition with derivation = constraint.
* 描述: 在資源上的一組約束，以結構定義(structure definition)做表示，derivation = constraint 意思是該結構定義是基於現有資源的修改或約束。
* 結構定義（structure definition）: 一種用於描述 FHIR 資源的結構、內容和行為的規範。
* The verb 'profile', or 'profiling', is used to describe the process of creating a profile.
* Profile 或 Profiling 是指建立 Profile 的過程。
#### 舉例
醫療機構可能有特定的要求：
* 必須記錄患者的國籍。
* 需要患者的出生日期，但不需要患者的出生時間。
* 患者的地址必須包含國家、城市、街道，但可以不包含郵遞區號。
為了滿足以上需求，你可以為患者資源建立一個 profile。這個 profile 是基於患者資源定義的結構定義，它新增了對患者資源的一些約束和調整：
* 新增一個國籍（nationality）屬性。
* 修改出生日期屬性，移除出生時間。
* 修改地址（address）屬性，只留下國家、城市和街道。
這個 profile 由結構定義表示，定義了患者資源在特定情境下的需求。如此一來，在你的醫療機構中，患者資源就必須滿足這些要求，從而確保數據的一致性和符合機構的政策。這就是 profiling。
# 規劃
根據以上的運動處方情境，列出初步的需求。
功能需求
---
#### 運動計劃管理
* 能夠制定並更新運動計劃，包括訂定運動目標和定期檢查。
* 提供自定義的運動計劃，包括中等至劇烈運動、重訓、每週運動天數、分鐘數等。
#### 數據追蹤和同步
* 使用者可以記錄並追蹤自己的運動水平，包括心率、步數、運動時間等。
* 自動同步設備（如手機或智慧手錶）中的運動數據到 App。
* 將數據同步到電子健康記錄（EHR）系統中，提供醫生即時了解患者情況。
#### 健康指南
* 提供健康指南，例如飲食建議、運動建議，以及生活方式改變建議等。
* 針對患者的活動水平提出改進建議。
#### 報告與反饋
* 提供報告和回饋功能，顯示運動進展和健康狀況。
* 讓使用者看到自己運動進度的數據視覺化呈現。
#### 通知與提醒
* 運動提醒和激勵功能。
* 透過 App 跟使用者溝通，並適時提供建議。
技術需求
---
#### FHIR 支援
* 透過 FHIR server 在 EHR 和 PHR 之間交換數據。
* 透過執行 FHIR 查詢，取得運動計劃、目標和其他與運動相關的資源。
#### 使用者身份驗證
* 使用 [SMART on FHIR 授權過程](https://hl7.org/fhir/smart-app-launch/app-launch.html)進行用戶身份驗證，確保使用者的隱私和數據安全。
* 授予患者及醫生等不同層級的權限。
#### 數據安全
* 確保數據傳輸過程和儲存過程中的安全。
* 數據加密或其他數據保護措施
FHIR Resources
---
#### [Patient](https://www.hl7.org/fhir/patient.html)
當需要識別和儲存患者的基本信息時使用。
* 使用時機: 當 Khatun 第一次到診所進行健康檢查時，診所會建立或更新 Khatun 的 Patient 資源，包括他的姓名、出生日期、聯絡方式等。
* POST URL: POST /Patient
* GET URL: GET /Patient/{id} (例如：GET /Patient/A123456789)
* 範例JSON:
```
{
"resourceType": "Patient",
"id": "khatun",
"identifier": [
{
"system": "http://hospital.smarthealthit.org",
"value": "A123456789"
}
],
"active": true,
"name": [
{
"use": "official",
"family": "Khatun",
"given": ["Patient"]
}
],
"telecom": [
{
"system": "email",
"value": "khatun@example.com",
"use": "home"
}
],
"gender": "male",
"birthDate": "1969-01-01"
}
```
#### [CarePlan](https://www.hl7.org/fhir/careplan.html)
當需要制定和管理患者的整體健康計劃，包括運動處方時使用。
* 使用時機: Patel 醫生為 Khatun 設計了一個運動計劃，這個計劃會被記錄在 CarePlan 資源中。
* POST URL: POST /CarePlan
* GET URL: GET /CarePlan/{id} (例如：GET /CarePlan/exercise-plan)
* 範例JSON:
```
{
"resourceType": "CarePlan",
"id": "exercise-plan",
"status": "active",
"intent": "plan",
"title": "Exercise Plan",
"subject": {
"reference": "Patient/A123456789"
},
"period": {
"start": "2024-05-22",
"end": "2024-11-22"
},
"activity": [
{
"detail": {
"kind": "ServiceRequest",
"code": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "229065009",
"display": "Physical exercise therapy"
}
],
"text": "Weekly moderate to vigorous exercise"
},
"status": "scheduled",
"scheduledTiming": {
"repeat": {
"frequency": 5,
"period": 1,
"periodUnit": "wk"
}
}
}
}
]
}
```
#### [Goal](https://www.hl7.org/fhir/careplan.html)
當需要設定和追蹤患者的健康目標時使用。
* 使用時機: Khatun 的運動目標是每週達到至少 100 分鐘的中等至劇烈運動。這個目標會被記錄在 Goal 資源中，並與 CarePlan 資源相關聯。
* POST URL: POST /Goal
* GET URL: GET /Goal/{id} (例如：GET /Goal/exercise-goal)
* 範例JSON:
```
{
"resourceType": "Goal",
"id": "exercise-goal",
"lifecycleStatus": "active",
"description": {
"text": "Achieve at least 100 minutes of moderate to vigorous exercise per week"
},
"subject": {
"reference": "Patient/A123456789"
},
"target": [
{
"measure": {
"coding": [
{
"system": "http://loinc.org",
"code": "55423-8",
"display": "Exercise minutes per week"
}
],
"text": "Exercise minutes per week"
},
"detailQuantity": {
"value": 100,
"unit": "minutes",
"system": "http://unitsofmeasure.org",
"code": "min"
},
"dueDate": "2024-11-22"
}
]
}
```
#### [ServiceRequest](https://www.hl7.org/fhir/servicerequest.html)
當醫生需要開立醫療指令，包括運動處方時使用。
* 使用時機: Patel 醫生開立了一個運動處方，要求 Khatun 每週進行至少 100 分鐘的中等至劇烈運動。這個指令會被記錄在 ServiceRequest 資源中。
* POST URL: POST /ServiceRequest
* GET URL: GET /ServiceRequest/{id} (例如：GET /ServiceRequest/exercise-prescription)
* 範例JSON:
```
{
"resourceType": "ServiceRequest",
"id": "exercise-prescription",
"status": "active",
"intent": "order",
"code": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "229065009",
"display": "Physical exercise therapy"
}
],
"text": "Exercise Prescription"
},
"subject": {
"reference": "Patient/A123456789"
},
"occurrencePeriod": {
"start": "2024-05-22",
"end": "2024-11-22"
}
}
```
#### [Observation](https://www.hl7.org/fhir/observation.html)
記錄和追蹤患者的健康數據和觀察結果時使用。
* 使用時機: Khatun 使用 App 記錄他的每日運動分鐘數、心率和步數。這些數據會被記錄在 Observation 資源中，並定期同步到 PHR 和 EHR 系統。
* POST URL: POST /Observation
* GET URL: GET /Observation/{id} (例如：GET /Observation/exercise-observation)
* 範例JSON:
```
{
"resourceType": "Observation",
"id": "exercise-observation",
"status": "final",
"category": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
"code": "activity",
"display": "Activity"
}
]
}
],
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "55423-8",
"display": "Exercise minutes per week"
}
],
"text": "Exercise minutes per week"
},
"subject": {
"reference": "Patient/A123456789"
},
"effectiveDateTime": "2024-05-22T00:00:00Z",
"valueQuantity": {
"value": 120,
"unit": "minutes",
"system": "http://unitsofmeasure.org",
"code": "min"
}
}
```
###### tags: `FHIR` `HL7`
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