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A DEEPER DIVE INTO HL7 FHIRDAVID HAY | JULY 2016
Page 2 • 2016 © Orion Health™ group of companies
DR. DAVID HAYMedical Doctor
Chair of HL7 New Zealand
Co-chair FHIR Management Group
Product Strategist Orion Health
Blog: fhirblog.com
Tooling: clinFHIR.com
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Agenda
▸ This talk– More about Resources
• Datatype• References• Coded data• Terminology
– Exchanging information• Interoperability Paradigms
– Profiling FHIR– Next steps for New Zealand
MORE ON RESOURCES
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Scope of resources
▸ Clinical– General– Care Provision– Medication / Immunizations– Diagnostics / Genomics
▸ Identification– Individuals, Groups, Entities
▸ Workflow– Patient Management– Decision Support / Quality
▸ Infrastructure– Documents– Exchange
▸ Conformance– Terminology– Content
▸ Financial– Support– Billing– Payment
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Clinical Resources
GeneralAllergyIntolerance
Condition (Problem)Procedure
ClinicalImpressionFamilyMemberHistory
RiskAssessment
DetectedIssue
Care ProvisionCarePlan
GoalReferralRequest
ProcedureRequestNutritionOrder
VisionPrescription
Medication & Immunization
MedicationMedicationOrder
MedicationAdministrationMedicationDispense MedicationStatement
ImmunizationImmunizationRecommendation
DiagnosticsObservation
DiagnosticReportDiagnosticOrder
Specimen BodySite
ImagingStudy
Clinical
http://hl7.org/fhir/resourcelist.html
Resource example
Resource Identity & Metadata
Human Readable Summary
Extension with URL to definition
Standard Data:• MRN• Name• Gender• Birth Date• Provider
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Definition
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Primitive data types
instant
decimal
integer
unsignedInt postiveInt code idoid
markdown
base64Binary string url
boolean
dateTimetime date
Element
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Complex data types
Ratio
Timing
Coding
Age Distance SimpleQuantity Duration Count
AttachmentPeriod Range
Element
Identifier
Signature
CodeableConcept Quantity SampledData ContactPoint
HumanName
Annotation
Address
Money
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References between resourcesCoded PropertiestypebodySuiteindicationperformer.rolecomplicationrelatedItem.type
Standard Propertiesidentifier (Identifier)
Performed (Datetime)
Procedure
Patient
Diagnostic ReportCondition
Subject
ReportRelatedItem
Encounter Performer
Encounter Practitioner
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Coded types
▸ Why have coded data ?▸ code, Coding, CodeableConcept, (Quantity)▸ Possible values defined in ValueSet resource
– Binding Strength• Required (must come from set)• Extensible (may use alternate if have to)
– Profile can tighten
• Preferred (don’t have to, but should)• Example (set isn’t specified)
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ValueSet resource
▸ Defines list of possible values for a particular context▸ Can reference external Terminologies
– Or define own sets▸ Why?
– A common valueSet improves recording consistency – Improves user experience (pick lists)
▸ Examples in New Zealand– ED diagnoses (derived from SNOMED)– NZ POCS (Pathology Observation Code Set) (derived from LOINC)– List of NZ Iwi (defined in ValueSet)
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Terminology Sub-system
▸ SNOMED CT ▸ LOINC ▸ ICD 9/10▸ A drug formulary - NZULM▸ New Zealand DHBs
Code System:Defines a set of concepts with a
coherent meaning
CodeDisplay
Definition
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Terminology Sub-system
Code System:Defines a set of concepts with a
coherent meaning
CodeDisplay
Definition
Value Set:A selection of a set of codes for use in a
particular context
Selects
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Terminology Sub-system
Code System:Defines a set of concepts with a
coherent meaning
CodeDisplay
Definition
Value Set:A selection of a set of codes for use in a
particular context
Selects Binds Profile: Type and Value
set reference
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Terminology Sub-system
Code System:Defines a set of concepts with a
coherent meaning
CodeDisplay
Definition
Value Set:A selection of a set of codes for use in a
particular context
Selects Binds Profile: Type and Value
set reference
Resource Instance: code/
Coding/CodeableConcept
Refers to
Conforms
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Terminology Server
▸ Provides ‘services’ for consumers to access terminology
– Hide the complex stuff from a consumer▸ Uses Operations framework
– Get definition for a concept– Find a concept
• Within a ValueSet• Find matching
Terms• Get Term
Definition
SHARING INFORMATION
12
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Interoperability Paradigms
REST Documents
Messages Services(Operations)
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REST (API)
▸ “Representational State Transfer” – an architecture for how to connect systems in real time
▸ Uses HTTP/S▸ Simple to use▸ Familiar to developers▸ Very commonly used outside of healthCare – especially mobile
– Google, Facebook, Twitter– JASON report in US called out the lack of an API
▸ CRUD
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Documents and Messages
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Services / Operations
▸ For more complex logic– Especially server side
▸ Real-time▸ Key part of ecosystem▸ Examples
– Prescribing with DSS– Terminology– Immunization protocols
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Regardless of paradigm, the content is the same…
The Same Resources
FHIRRepository
Message
RESTNational Exchange
FHIR Document
PROFILES
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Profiling
▸ Many different contexts in healthcare, but want a single set of Resources▸ Need to be able to describe ‘usage of FHIR’ based on context and country▸ Allow for these usage statements to:
– Authored in a structured manner– Published in a repository– Discoverable– Used as the basis for validation, code, report and UI generation.
▸ 2 main aspects:– Adding an extension– Constraining a resource
▸ Profiling adapts FHIR for specific scenarios
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Extensions
▸ Only most common elements in base resource– Keeps the resources small– (Adding everything was the problem with version 3)
▸ Extensions allow other elements to be defined– Same capabilities (dataType) as core elements
• Including resource references and terminology bindings– Wire format unchanged– Can extend properties and datatypes as well as the resource
▸ Extensions are normal– Expect all real implementations to use extensions
▸ ‘normal’ and modifierExtensions– Normal extensions can be ignored by a recipient– Unknown modifierExtensions cannot be ignored
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Profiling a resource
Note: hardly any mandatory elements in the core spec!
Require that the identifier uses the NHI– and is required
Limit names to just 1 (instead of 0..*)
Limit maritalStatus to another set of codes that extends the one from HL7 international
Add an extension to support ‘Iwi’
Don’t support photo
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Practical steps exposing FHIR data
▸ Gap analysis– Extensions required– Elements unsupported
▸ Find or Create extension definitions (StructureDefinition)– Prefer re-use
▸ Any other ‘conformance’ resources– NamingSystem– ValueSet
▸ Build profile▸ Update Conformance resource▸ Create samples
– Can use clinFHIR▸ Possible create Implementation Guide
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Security
▸ FHIR is not a security standard– Leverages existing standards –
for example• TLS• OAuth2
▸ Support in the specification– Security tags (metadata)– Specialized resources
• Provenance• AuditEvent
▸ More detail– http://hl7.org/fhir/security.html
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Building on FHIR
▸ Ecosystem– SMART
▸ CDS-Hooks– Integrate Decision Support
▸ Population Health▸ Decision Support
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▸ Infrastructure– Registries– Terminology Servers– Test servers– Security– National Services
• HPI, NHI
▸ Governance– Clinically based
• ValueSets, Profiles, Implementation Guides
▸ Pilots▸ Education▸ Support
Next steps for New Zealand
Page 33
▸ From HL7 – http://hl7.org/fhir/index.html– wiki.hl7.org/index.php?title=FHIR– http://www.fhir.org/
▸ Community– https://chat.fhir.org/– List server ([email protected] )– Stack Overflow (tag FHIR)
▸ Blogs– http://www.healthintersections.com.au/– https://fhirblog.com/– https://thefhirplace.com/
▸ Libraries– Java (http://hapifhir.io/)– C# (NuGet HL7.FHIR)
▸ Tooling– Forge (http://fhir.furore.com/Forge)– http://clinfhir.com/
▸ Test servers– http://wiki.hl7.org/index.php?
title=Publicly_Available_FHIR_Servers_for_testing
▸ White papers – http://orionhealth.com– FHIR - Sparking innovation in health
information sharing– FHIR – Ignites healthcare sharing
More information
Page 34 • 2016 © Orion Health™ group of companies
In Summary
▸ FHIR is the latest HL7 interoperability standard▸ Enormous interest locally and internationally▸ Allows clinicians and patients to be more involved▸ Promises to revolutionise sharing of healthcare information▸ Is not a silver bullet▸ FHIR promotes Innovation▸ FHIR is disruptive▸ FHIR IS in your future
For more information on FHIR see here: http://hl7.org/fhir/index.html