HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.
Amsterdam, November 20 - 22 | @HL7 @FirelyTeam | #fhirdevdays | www.devdays.com/us
FHIR Documents
René Spronk, trainer/training coordinator, Firely/Ringholm
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Agenda
• FHIR Documents – core components
• Document Profiling
• FHIR Exchange Patterns
• CDA and FHIR Documents
• Document Metadata / IHE XDS
• Documents v. Clinical Notes
This presentation is focused on FHIR Douments. Knowledge of the HL7 CDA standard is not required.
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FHIR Example: Narrative with low level of coding
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Text vs. Coding
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• Two extremes in today's data processing
• “Narrative text” vs. “Fields in a database”
• What’s the optimal hybrid mixture ?
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FHIR Documents
• Focus is on persistence
• No workflow involved
• other than post/retrieve document
• Need tight rules over authenticated content
• Want to communicate multiple resources with control over how data is presented
• Data spans multiple resources
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Adam Everyman use case - let’s document the follow-up Encounter
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Document Example – Adam Everyman
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Document Structure = a bundle
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The Composition resource
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Narrative
• Narrative text can be in several places
• Rules control how the document is presented (for humans) so the text has a consistent order:
• The subject resource, Patient.text
• The Composition resource, Composition.text
• All the section.text(s)
• The presentation of the document is called the 'attested content' of the document • For implications see “Document Presentation”
http://hl7.org/fhir/documents.html
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FHIR Documents: Human interoperability guaranteed
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ACP on Clinical Documentation
• Structured data should be captured only where they are useful in care delivery or essential for quality assessment or reporting.
• .. where the data element cannot be readily abstracted from the note with sufficient accuracy by using natural language processing
Source (Jan. 2015): Clinical Documentation in the 21st Century: A Policy Position Paper From the
American College of Physicians, http://annals.org/data/Journals/AIM/0/0000605-201502030-00193.pdf
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<section>
<text>
</text>
<entry>
<reference value="Observation/12486"/>
<!– Observation: systolic = 120 --> </entry>
<entry>
<reference value=" Observation/86499"/>
<!– Observation: diasystolic = 80 --> </entry>
</section>
Generated text narrative is fully derived from structured content
Blood
Pressure 120 80
Database
... ...
systolicBP int
diastolicBP int
... ...
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Blood pressure 120/80</p>
</div>
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<section>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Patient with onset of asthma
in his teens</p>
</div>
</text>
</section>
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Narrative based narrative is richer than structured content (‘additional’ information)
Database
... ...
familyHistory text
... ...
Family
History:
Patient with onset of
asthma in his teens
<entry>
<reference value=" Observation/12486"/>
<!- Observation: asthma -->
</entry>
</section>
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What are the “medical document principles” ?
• Persistence – A document continues to exist in an unaltered state
• Stewardship – A document is maintained by an organization entrusted with its care.
• Potential for authentication - A document is an assemblage of information that is intended to be legally authenticated.
• Context - A document establishes the default context for its contents.
• Wholeness - Authentication of a document applies to the whole and does not apply to portions of the document without the full context of the document.
• Human readability – A document is human readable.
Source: HL7 CDA specification
FHIR Documents certainly meet these criteria.
HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.
Document Profiling
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Document Profile
• Profile of the Composition resource
• Profiles of the section content
• StructureDefinition
• GraphDefinition
• Implementation Guide
• E.g. IPS, http://hl7.org/fhir/uv/ips/2018Sep/
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Composition structured and coded
Sections •Salutation
•Problem/Subjective
•History
•Physcial/Objective
•Diagnoses
•Epicrise
•Plan
•............
•Family History
•Past Medical History
•Admission diagnosis
•Nursing diagnosis
•Discharge diagnosis
coded entry (ICD 10)
HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.
FHIR Exchange Patterns
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Paradigms
• FHIR supports 4 exchange patterns
REST Documents
Messages Services
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When to avoid Documents?
•Need for workflow • Request/response, decision support
•Data is dynamic
• i.e. want view of data now, not at time of authorship
• Multiple contributors over time
•Resources need to be accessed/manipulated independently
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Exchange patterns - characteristics
Document
Persisting attested content
Rules for rendering
No workflow support
No dynamic data
Unit of work = * resources
REST
CRUD, lightweight
Client driven orchestration
Unit of work = single resource
‘Natural’ servers
Messaging
Event driven
Behavioral expectation
Always request/response Async option
Server driven orchestration
Stuff other than CRUD Unit of work = * resources
HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.
CDA and FHIR Documents
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CDA to FHIR
Document bridge
Hospital System A
FHIR
Documents
Note: Documents are compositions,
• No update semantics
• Context?
• Wholeness?
FHIR
Repository
FHIR
REST
FHIR Document
processor
CDA and FHIR
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Mapping
• FHIR Documents have a wider scope than CDA (e.g. subjects other than a patient)
• Made more complex by human-readable nature
• In FHIR presentation determined by author, not by user of the document (as is the case with CDA)
• Best practice
• CDA header to Composition mapping
• CDA Template to resource mapping
• CDA Narrative to XHTML mapping
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Mapping CDA to FHIR
• Mapping includes
• Profile of the Composition resource
• Mapping of CDA header to Composition
• High-level mapping of CDA templates to FHIR profiles
• Main interest in this mapping in the US
• C-CDA to FHIR, http://wiki.hl7.org/index.php?title=C-CDA_on_FHIR
• Comparison:
• http://hl7.org/fhir/comparison-cda.html
• Video:
• https://vimeo.com/141875366
HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.
Document Metadata / XDS
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DocumentReference • Describes a document; metadata of the document
Contains, or
references,
a document
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Matadata
• Mainly a mapping of FHIR Header data elements to DocumentReference data elements • However: they need not be the same on some cases; document
lifecycle status
• Rich Metadata is essential for document management (DMS applications, IHE XDS) • E.g. Query, access control, provenance
HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.
Document v. Clinical Notes
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Varying Formats of Clinical Notes
Text or XHTML
RTF or PDF or .doc
Mixed document: structured FHIR resources, and narrative
Slide courtesy of Michelle Miller / Brett Marquard
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DocumentReference – Mixed structure and narrative May have 2:
1 Binary Resource (e.g. C-CDA, text, PDF, rtf)
2 Composition (if there’s strutured content)
[base]/Binary
[base]/Composition
Slide courtesy of Michelle Miller / Brett Marquard
HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.
Summary
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Summary
• FHIR Documents
• The Document exchange mechanism should be used if the focus is on persistence, and on narrative which is the authenticated content.
• Functionality of CDA, and more.
• Profiling (Implemetation Guide) is a necessity
• DocumentReference resource
• DMS archives, IHE XDS, Clinical Notes
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Example: Discharge Letter for Adam Everyman
• XML + HTML View
• STU3 Example
• https://bit.ly/2lE4KQx (zip)
HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.
Amsterdam, November 20 - 22 | @HL7 @FirelyTeam | #fhirdevdays | www.devdays.com/us
FHIR Documents
René Spronk, trainer/training coordinator, Firely/Ringholm