Date post: | 16-Feb-2017 |
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Healthcare |
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Access to health data
Ewout KramerFHIR Core team (and software developer) Furore (Amsterdam, NL)
email: [email protected]: http://thefhirplace.com
http://fhir.furore.comskype: ewoutkramer
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Common Nordic Architecture for Telemedicine
?
Align to Continua TAN-IF, PAN-IF and LAN-IF
HL7 FHIR Observation (CDG 2017 WAN-IF)
HL7 FHIR Questionnaire (CDG 2017 WAN-IF)
SOAP (Green CDA) → FHIR ?
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Personal Info Exchange
“In many ways this overlaps with the innovation framework labeled ‘SMART on FHIR’”
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REST AND DOCUMENTS
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“Here is the patient’s pregnancy file”
““Pass the DICOM metadata of last visit’s MRIs”
“My training diary entries for today”
Strong notion of inter-human “bulk transfer”(of data, responsibility)
Document-based data
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Beware of the document
Document based transfer is popular:
• C-CDA in the US• XDS-based infrastructure on a national scale• Aligns with practitioner-to-practitioner human
communication
But it does not fit every usecase!
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Longitudinal data
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Human/System interactions
Helse Vest Self booking Project
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“I’d like to reschedule my appointment”
“Which medication is the patient using?”
“Your new lab results are ready”
Strong notion of fine-grained app-to-server “communication”(of events, facts, actions)
Request/Response
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“The problem with this approach is that the CDA is really only a container for the information.”
“The recent introduction of FHIR by HL7 is in JASON’s view a signifi cant improvement over CDA. FHIR attempts to standardize the exchange of information through a set of modular components that are called Resources”
“Data for Individual Health” – US JASON Taskforce, November 2014
Warning!
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What about XDS in the Nordic countries? SE: (…) As a result, there is no national EHR
database, nor is there a demand for a document exchange infrastructure
NO: A possible future migration to XDS-based document exchange is being considered.
DK: The future for clinical exchange (…) is basically based on XDS based document exchange.
Source: Towards a Nordic Reference Architecture for Personal Connected health and care TechnologyLars Kristian Roland, Architect at the Norwegian Directorate of e Health; Johan Eltes, Deputy CTO Inera AB, Thor Schliemann, Architect atthe Danish Health Data Authority.
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SMART ON FHIRIntegrating in the EMR
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Objective In early 2010, Harvard Medical School and Boston Children’s Hospital began an interoperability project with the distinctive goal of developing a platform to enable medical applications to be written once and run unmodified across different healthcare IT systems. The project was called Substitutable Medical Applications and Reusable Technologies (SMART).
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Motivation….
Turn bright ideas into real apps Take away the technology burdens
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Why ?
App choice (substitutability) for users
Low barriers to entry for developers
Apps can run in systems by different vendors
Apps can run in different contexts (e.g. EHR
and Patient Portal)
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SMART The App Platform for Healthcare
Open source development tools and resources
Standard formats and protocols for healthcare data
Public gallery to connect apps and users
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SMART = FHIR + …
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SMART Authorization
Based on OAuth2 standard
Two launch workflows EHR/Portal Launch – user picks an app from
within EHR (EHR can pass along context like encounter and patient)
Standalone Launch – user launches app and picks an EHR server (can run from mobile devices)
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SMART Authorization
Slightly simplified - details at: http://docs.smarthealthit.org/authorization/
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Agree on actual codes
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Additional constraints
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App Gallery
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Growth analyzer
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Run a demo…
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Launch context
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CDS-HooksEMR
Medication-prescribe
Order-review
Patient-view
Events in theEMR
External services hooked to the events
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Source: https://github.com/cds-hooks/cds-hooks/wiki
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Live demo
Try: http://hooks.fhir.me/#"activity":"medication-prescribe"
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Uses for CDS hooks
Opening patient record prompts action in trial selection system
Placing a medication order prompts (pricing/interaction) guidance in EHR
Placing a medication order returns medication info in foreign language of patient
Opening a patient adds links to apps with detailed genomic results
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Common theme
SMART and CDS-hooks open up the EMR as a platforms in which 3rd-parties can become part of the workflow
3rd party suppliers can provide more specialized functionality than an EMR would every implement
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Argonaut Project Initiative to get FHIR and SMART ready for broad use by
testing standards with widely adopted EHR systems Founding organizations:
EHR Vendors: athenahealth, Cerner, Epic, McKesson, MEDITECH, Surescripts
Healthcare Organizations and Companies: Beth Israel Deaconess Medical Center, Intermountain Health,
Mayo Clinic, Partners Healthcare System, SMART at Boston Children’s Hospital Informatics Program, The Advisory Board Company, Accenture
Implementation program – free to participate 20+ vendors Series of development sprints
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FHIR QUESTIONNAIRES
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What is Questionnaire for? Questionnaires are a typical means for
capturing information from humans Both within and outside of healthcare
Provide great control over data capture What data is requested How question is phrased Constraints on allowed responses In what order questions are presented Under what circumstances information is
needed
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Item/question
Item-group
Nested Item/question
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Questionnaire(Response)
Questionnaire: The “Definition” of the content to be captured What questions(items) are to be asked when and
how? QuestionnaireResponse: A completed (or
partially) completed instance of a Qnnaire There may be hundreds (or thousands) of
QuestionnaireResponses for one Questionnaire QuestionnaireResponses can exist without a
Questionnaire at all (paper, legacy)
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Questionnaire model
Linkid: ties questionnaire and responseRequired: yes/noRepeats: yes/no
status: Is this questionnaire still active?date: When did this status become effectivesubjectType: What must QuestionnaireResponse.subject be?concept: Code for the overall questionnaire
Nests!
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Item types
There are 3 main types of items in a questionnaire: display – Cannot have an answer or nested items
– just text for display group – Cannot have an answer and must have
nested groups and/or questions question (abstract) – Can have an answer, but
may also have nested items
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QuestionnaireResponse
Author, source and subject!
Here’s linkId again!
Answer can point to a real Resource!
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Example Questionnaire / Response workflow
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Standard FHIR services
Questionnaire/$populate Generate a QuestionnaireResponse for a specified
Questionnaire, optionally filling in data from a local or submitted data
Requires business logic in server to know “how” to populate
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Usage
Forms in apps US ‘Structured Data Capture’ (SDC) project
Pre-population of forms from CDA R2 data http://wiki.siframework.org/
Structured+Data+Capture+Initiative http://hl7.org/fhir/sdc/sdc.html
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Render-a-Questionnaire
http://smartq.azurewebsites.net/Home/SelectSurvey
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C3-PRO + ResearchKit
Source: http://c3-pro.chip.org/architecture.html
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Caveat
There is overlap between Questionnaires and other Resources
Questionnaire's flexible structure can easily be misused to capture any data
Choice between Questionnaires or Resources may be dictated by the procedure of collection and recording
No binary choice!
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DEVICE OBSERVATION – A PROFILE
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The Observation
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Points of Interest
Subject: the Patient and/or the Device
effective[x] and issued
Component versus Related
Device and DeviceMetric
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Example instance
http://spark.furore.com/fhir/Observation/satO2?_format=xml
http://hl7.org/fhir/observation-example-satO2.html
Take a look at the xml!
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Continua WAN
Uses IEEE 11073 and IHE-PCDProfile
Semantically equivalent toFHIR DeviceMetricObservation profile
(FHIR will be used in 2017 CDG WAN-IF?)
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IEEE 11073 in FHIR
DeviceComponent Resource(any medical device that does not represent a metric, e.g. MDS, VMD, or Channel)
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IEEE 11073 in FHIR
DeviceMetric Resource(mandatory static properties that characterize a direct or derived, quantitative or qualitative biosignal measurement, setting, or calculation produced by a medical device)
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DeviceMetric Observation Constrained version of Observation
Subject: only Patient or Device No: Encounter link, “issued”, “dataAbsentReason”,
specimen Mandatory: effectiveDateTime (not Period) Mandatory link to DeviceMetric (not to Device) 15x “Must Support”
Let’s try this in Forge Define SpO2 DeviceMetricObservation…
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PATIENT ACCESS OR PATIENT IN THE CENTER?
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Your “Mobile” device becomes the Big Aggregator and Coordinator of data and functionality
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In the financial sector…
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Apple ResearchKit
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Where is the Portal? PHR?
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Reality?
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Reality?
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FINALLY…
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Tutorials All the latest information on FHIR
Connectathon Meet fellow developers Put FHIR to the test
Networking FHIR experts and
authors on hand
http://fhir.furore.com/devdays