Remote Anamnesis Implementation Guide
0.1.0 - ci-build

Remote Anamnesis Implementation Guide - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

## Remote Anamnesis

Official URL: http://remote-anamnesis.na.icar.cnr/ImplementationGuide/remoteanamnesis | Version: 0.1.0
Active as of 2025-08-08 | Computable Name: RemoteAnamnesis

### Scope

This Implementation Guide aims to define, according to the specifications of the HL7 FHIR R4 standard, a structured set of profiles, extensions, and terminology artifacts intended to support the remote management of patient anamnesis. The Implementation Guide serves as a technical-operational reference for the adoption of interoperable solutions in the collection, representation, and transmission of anamnesis data, ensuring compliance with national and international standards, and in particular with the FSE 2.0 model.

### Contesto

The growing use of telemedicine and the development of digital health care platforms have created the need for solutions that ensure the structured, secure, and interoperable collection of patients’ clinical information.

In this context, anamnesis (medical history) is essential for effective clinical evaluation, particularly when direct interaction between patients and physicians is limited, as in tele-visits, teleconsultations, and remote monitoring. The ability to conduct remote consultations makes adopting digital tools that can collect, represent, and transmit clinical data in a structured way that complies with national and international interoperability standards essential.

This guide focuses on the breast cancer care scenario specifically, where accurate anamnesis collection plays a critical role in diagnosis, treatment planning, and ongoing monitoring. Because breast cancer patients often require multidisciplinary management and frequent follow-ups, remote anamnesis collection is not only convenient, it is also necessary to maintain continuity of care and patient safety.

This work describes the adoption of a standards-based methodological approach to designing an interoperable system for remote anamnesis collection. The system is designed to integrate seamlessly with tele-visit platforms, aligning with the technical specifications of the Electronic Health Record (Fascicolo Sanitario Elettronico, FSE) and HL7 guidelines. This facilitates interoperability and data consistency across healthcare systems.

### Dependence

IG | Package | FHIR | Comment
--- | --- | --- | ---
Remote Anamnesis Implementation Guide | remoteanamnesis#0.1.0 | R4 |
HL7 Terminology (THO) | hl7.terminology.r4#6.5.0 | R4 | Automatically added as a dependency - all IGs depend on HL7 Terminology
FHIR Extensions Pack | hl7.fhir.uv.extensions.r4#5.3.0-ballot-tc1 | R4 | Automatically added as a dependency - all IGs depend on the HL7 Extension Pack

Package hl7.fhir.uv.extensions.r4#5.3.0-ballot-tc1 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Sun, Aug 3, 2025 06:28+1000+10:00)

### Details

#### Cross-Version Analysis

This is an R4 IG. None of the features it uses are changed in R4B, so it can be used as is with R4B} systems. Packages for both R4 (remoteanamnesis.r4) and R4B (remoteanamnesis.r4b) are available.

### Implementation Guide

This is a Beta Implementation Guide for collecting patient medical history data.

### Authors and contributors

Role | Name | Organization | e-mail
--- | --- | --- | ---
Author | Teresa Conte | ICAR-CNR | teresa.conte@icar.cnr.it
| Mario Sicuranza | ICAR-CNR | mario.sicuranza@icar.cnr.it
Contributor |  |  |

### Intellectual Property Statements

This publication includes IP covered under the following statements.

- This material contains content from LOINC. LOINC is copyright © 1995-2020, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc.
  Show Usage
  - LOINC: Consent_Patient
- This material contains content that is copyright of SNOMED International. Implementers of these specifications must have the appropriate SNOMED CT Affiliate license - for more information contact https://www.snomed.org/get-snomed or info@snomed.org.
  Show Usage
  - SNOMED Clinical Terms&reg; (SNOMED CT&reg;): AllergyIntolerance/allergyintolerance-penicillin, Condition/Condition-Patient-001... Show 17 more, Condition/Condition-Patient-002, Consent_Patient, DOSA, DOSDIR, DiagnosticReport/DiagnosticReport-Patient-001, FamilyMemberHistory/FamilyMemberHistory-Patient-001, LesionSideVS, Medication/Medication-Patient-001, Medication/Medication-Patient-002, MedicationStatement/Medication-Statement-Patient-001, MedicationStatement/Medication-Statement-patient-002, Medication_Patient, Medication_Statement_Patient, Observation/Observation-Patient-Fever-001, Observation/Observation-Patient-HighBloodPressure-001, Observation/Observation-Patient-Pain-001 and Observation_Axis
- This material derives from the HL7 Terminology (THO). THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license.html
  Show Usage
  - AllergyIntolerance Clinical Status Codes: AllergyIntolerance/allergyintolerance-penicillin
  - Condition Clinical Status Codes: Condition/Condition-Patient-001 and Condition/Condition-Patient-002
  - Consent Category Codes: Consent_Patient
  - Consent Scope Codes: Consent_Patient
  - Observation Category Codes: OBSVS, Observation/Observation-Patient-Fever-001... Show 7 more, Observation/Observation-Patient-HighBloodPressure-001, Observation/Observation-Patient-Pain-001, Observation_Axis, Observation_Circularity, Observation_OrientationAngle, Observation_Patient and Observation_PerimeterRegularity
  - Practitioner role: Consent_Patient
  - ActReason: Consent_Patient
  - RoleCode: FamilyMemberHistory/FamilyMemberHistory-Patient-001
  - TimingEvent: Medication_Statement_Patient
- Using RxNorm codes of type SAB=RXNORM as this specification describes does not require a UMLS license. Access to the full set of RxNorm definitions, and/or additional use of other RxNorm structures and information requires a UMLS license. The use of RxNorm in this specification is pursuant to HL7's status as a licensee of the NLM UMLS. HL7's license does not convey the right to use RxNorm to any users of this specification; implementers must acquire a license to use RxNorm in their own right.
  Show Usage
  - RxNorm: AllergyIntolerance/allergyintolerance-penicillin