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FHIR for implementers in New Zealand

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A presentation in Christchurch aimed at implementers

Published in: Health & Medicine
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FHIR for implementers in New Zealand

  1. 1. FHIR forImplementers InNewZealand
  2. 2. Page 2 Thanks to our sponsors
  3. 3. Page 3 About me • Medical Doctor • Developer – EMR – Tooling: clinFHIR, conMan • HL7 Fellow • Chair Emeritus of HL7 New Zealand • Co-chair FHIR Management Group • Contractor – MOH, Rhapsody, CSIRO, HL7 Intl. • Blog: fhirblog.com 3
  4. 4. Page 4 Objectives for day • Understand the basics of FHIR • Feel confident to participate in a FHIR Implementation • Know how to use clinFHIR / conMan tooling • Know where to find more info and help • Build the local community! – Encourage people to comment on work…
  5. 5. Page 5 Agenda Time Activity 9.00 – 10.30 Technical Overview, Terminology 10.30 – 11.00 Morning tea 11.00 – 11.45 Profiling, Implementer support 11.45 – 12.30 Individual Exercises 12.30 - 1.15 Lunch 1.15 - 2.00 Exchange paradigms 2.00 – 2.30 National perspective – current projects, ecosystem, reviewing 2.30 – 3.00 Afternoon tea 3.00 – 3.30 Security & Additional standards 3.30 – 4.00 Exercises 4.00 – 4.30 Wrap up, unanswered questions, next steps
  6. 6. Page 6 Zulip chat https://chat.fhir.org/
  7. 7. Page 7 Technical Overview • What is FHIR • Resources • Resource Graphs (incl. clinFHIR) • Terminology – Interaction and resources • Exchange Paradigms – CRUD operations – Update operations • PUT, PATCH, Operation • Wire representation – Extensions & Contained • Implementer Support – Tooling and Libraries
  8. 8. Page 8 What is FHIR • Fast Healthcare Interoperability Resources • An HL7 Interoperability Standard – For sharing clinical information – No assumption on storage form – Focused on the now • (with an eye to the future) • 2 main parts – Content Model (Resources) – Exchange Specification • Extending into – Clinical Knowledge – Decision Support – Quality Measures – Also being used for persistence • Supported by a large community – https://chat.fhir.org/ – Libraries – Reference servers ® Health Level Seven and HL7 are registered trademarks of Health8
  9. 9. Page 9 Where can you use FHIR 9 ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. FHIR Application PHR FHIR API Library Database FHIR Integration Engine V3 V2
  10. 10. Page 10 Timeline: Where does FHIR fit? ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. FHIR Maturity model & releases 1980 1990 2000 2010 2020 FHIR CDA V3 V2 V2 1987 Start V3 1995 V3 CDA 2005 Fresh Look 2011 FHIR Release 4 2018
  11. 11. Page 11 Where is it going? • More resources • Moving resources to Normative – More implementation experience, connectathons • Moving beyond Interoperability – Extending into Clinical Knowledge • Decision Support • Quality Measures – Bulk extract and query – Research – Also being used for persistence • Associated standards – SMART – CDS-Hooks – Bulk Data • Accelerating implementations • Supporting the community ® Health Level Seven and HL7 are registered trademarks of Health11
  12. 12. Page 12 Who’s using it? • Vendors – Epic, Cerner, Allscripts – Apple – Microsoft – Google – Amazon • Countries – US - ONC – UK – Russia, Lithuania – Australia, New Zealand – Pretty much everywhere 12® Health Level Seven and HL7 are registered trademarks of Health
  13. 13. Page 13 Resources: What are they? • The Content Model • The Thing that is exchanged – Via REST ( FHIR Restful API), Messages, Documents • Informed by much past work inside & outside of HL7 – HL7: version 2, version 3 (RIM), CDA – Other SDO: openEHR, CIMI, ISO 13606, IHE, DICOM 13® Health Level Seven and HL7 are registered trademarks of Health
  14. 14. Page 14 Clinical Resource types General AllergyIntolerance Condition (Problem) Procedure ClinicalImpression FamilyMemberHistory RiskAssessment DetectedIssue Care Provision CarePlan CareTeam Goal ReferralRequest ProcedureRequest NutritionOrder VisionPrescription Medication & Immunization Medication MedicationRequest MedicationAdministration MedicationDispense MedicationStatement Immunization ImmunizationRecommendation Diagnostics Observation DiagnosticReport ProcedureRequest Specimen BodySite ImagingStudy Sequence
  15. 15. Page 15 References between resources 15 ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. PROCEDURE Patient Diagnostic reportCondition Subject Report Related Item Encounter Performer Encounter Practitioner http://hl7.org/fhir/references.html
  16. 16. Page 16 Recording a consultation 16 ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. 12-year-old-boy First consultation Complaining of pain in the right ear for 3 days with an elevated temperature. On examination, temperature 38°C and an inflamed right eardrum with no perforation. Diagnosis Otitis Media, and prescribed Amoxicillin 250mg 3 times per day for 7 days. Follow up consultation 2 days later returned with an itchy skin rash. No Breathing Normal. On examination, urticarial rash on both arms. No evidence meningitis. Diagnosis of penicillin allergy. Antibiotics changed to Erythromycin 250mg 4 times per day for 10 days. Patient Encounter Condition Observation Medication Allergy Intolerance
  17. 17. Page 17 First consultation as a Graph 17 ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
  18. 18. Page 18 Visualizing the connections: conMan 18 ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
  19. 19. Page 19 Demonstration http://conman.clinfhir.com/connectathon.html?event=nz  Build a resource graph for the first consultation - (Exercise 2 uses conMan)
  20. 20. Page 20 Resources: Type vs Instance • ‘Type’ is the definition in the spec – Like a template or a cookie cutter • ‘Instance’ is a ‘filled out’ type – Like a cookie • Take Patient: – Patient type (in spec) is what can be recorded for a patient • (Can alter with Profiling) – An actual patient is a particular instance of the Patient type 20® Health Level Seven and HL7 are registered trademarks of Health
  21. 21. Page 21 Contained resources • Resources instances generally stand alone – With references between them • Contained resources: – Resources ‘inside’ another – When doesn’t have separate identity • Wire format (‘contained’ element) • Library support http://hl7.org/fhir/references.html#contained
  22. 22. Page 22 Resource instance example Resource Identity & Metadata Human Readable Summary Extension with URL to definition Structured Data: •MRN •Name •Gender •Birth Date •Provider XML and JSON <valueString value=“jedi”/>
  23. 23. Page 23 Structured / coded data • Unstructured vs Structured vs Coded • Value: – Greatly improves quality of exchange – ‘semantic’ interoperability • Secondary uses – Decision Support – Analytics – Population Health – Reporting 23® Health Level Seven and HL7 are registered trademarks of Health
  24. 24. Page 24 Resource type structure and definition 24 ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. Examine the spec…
  25. 25. Page 25 Resource type Hierarchy Resource • Id • Meta Domain Resource • Text • Contained • Extensions Specific type Bundle
  26. 26. Page 26 Base Types • DataTypes – Each element in an instance is a single datatype • Spec indicates allowed types • Choice element – 2 classes of datatype • Primitive • Complex • Other types – MetaData – Element – Resource / Domain Resource – Logical Model 26® Health Level Seven and HL7 are registered trademarks of Health
  27. 27. Page 27 Data types: Primitive (R3) 27 ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. Based on w3c schema and ISO data types • Stick to the “80% rule” – only expose what most will use – Simplified instant Value : xs : dataTime 0..1 time Value : xs : Time 0..1 date Value : xs:gYear [xs:gYearMonth | Time 0..1 dateTime Value : xs:gYear [xs:gYearMonth | xs:date | Time 0..1 decimal integer Value : xs : int 0..1 Element Extension : Extension 0.. boolean value : xs:boolean 0..1 string Value : xs :string 0..1 uri Value : xs :anyURI 0..1 base64Binary Value : xs : base64Binary 0..1 unsignedint positiveInt code id oid Value : xs : decimal 0..1
  28. 28. Page 28 Ratio numerator: Quality [0..1] denominator: Quantity [0..1] Quantity value: decimal [0..1] comparator: code [0..1] QuantityComparator! units: string [0...1] system: uri [0..1] code: code [0..1] Range low: Quantity(SimpleQuantity) [0..1] high: Quantity(SimpleQuantity) [0..1] HumanName use: code [0..1] NameUse! text: String [0..1] family: String [0..*] given: String [0..*] prefix: String [0..*] suffix: String [0..*] period: Period [0..1] Identifier use: code [0..1] IdentifierUse! type: CodeableConcept [0..1] IdentifierType+ system: uri [0..1] value: String [0..1] period: Period [0..1] assigner: Reference [0..1] Organization Address use: code [0..1] AddressUse! type: code [0..1] AddressType! text: string [0..1] line: string [0..*] city: string [0..1] district: string [0..1] state: string [0..1] postalCode: string [0..1] country: string [0..1] period: Period 0...1 Coding system: uri [0..1] version: string [0..1] code: code [0..1] display: String [0..1] userSelected: boolean [0..1] Element extension: Extension 0..* Timing event: dataTime [0..*] code: CodeableConcept [0..1] TimingAbbreviation? Repeat bounds[x]: Type [0..1] Duration|Range|Period dount: Integer [0..1] dountMax: integer [0..1] duration: decimal [0..1] durationMax: decimal [0..1] durationUnit: code [0..1] UnitsOfTime! frequency: integer [0..1] frequencyMax: integer [0..1] period: decimal [0..1] periodMax: [0..1] periodUnit: code [0..1] UnitsOfTime dayOfWeek: code [0..*] DaysOfWeek! timeOfDay: time [0..*] when: Code [0..*] EventTiming! offset: unsginedInt [0..1] ContactPoint system: Code [0..1] ContactPointSystem! value: String [0..1] use: Code [0..1] ContactPointUse! rank: PositiveInt [0...1] period: Period [0..1] CodeableConcept coding: Coding [0..*] text: String [0..1] Attachment contentType: Code [0..1] MimeType! language: Code [0..1] CommonLanguages+ data: base64Binary [0..1] url: uri [0..1] size: unsignedInt [0..1] hash: base64binary [0..1] title: string [0..1] creation: dateTime [0..1] Period start: dateTime [0..1] end: dateTime [0..1] SampledData origin: Quantity(SimpleQuantity) [1..1] period: Decimal [1..1] factor: Decimal [0..1] lowerLimit: Decimal [0..1] upperLimit: Decial [0..1] dimensions: Positivelnt [1..1] data: String [1..1] Data types: Complex (R3) Signature type:Coding [1..*] Signature Type? when: Instant [1..1] who[x]: Type [1..1] uri | Reference(Practitioner|Related person|PatientDevice|Organization) onBehalfOf[x]: Type [0..1] uri|Reference(Practitioner|RelatedPers on|Pateint|Device|Organization) contentType: code [0..1] MimeType! blob: base64Binary [0..1] Annotation author[x]: Type [0..1] Reference(Practitioner|Patient| RelatedPerson)|string Time: dateTime [0..1] Text: string [1..1] repeat [0..1] 28
  29. 29. Page 29 DataType: Identifiers • Business identifiers – NHI, Driving License, CSC Card, Lab order number – Most resources have them (name is ‘identifier’ as well) • Identifier datatype – Key child elements • System – The ‘namespace’ within which the value is unique (uri) » NamingSystem resource to describe • Value – The actual value • Not the same as the resource Id
  30. 30. Page 30 Coded datatypes • Refer to a terminology • Code: "status" : "confirmed" • Coding: { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "C3214954", "display": "cashew nut allergenic extract Injectable" } • CodeableConcept: { "coding": [{ "system": "http://snomed.info/sct", "code": "39579001", "display": "Anaphylactic reaction“ }], "text" : "Anaphylaxis" } Datatypes in the spec…
  31. 31. Page 31 TERMINOLOGY
  32. 32. Page 32 Why have structured / coded data • Unstructured vs Structured vs Coded • Value: – Greatly improves quality of exchange – ‘semantic’ interoperability • Secondary uses – Decision Support – Analytics – Population Health – Reporting 32s of States
  33. 33. Page 33 Terminology Resources
  34. 34. Page 34 Terminology Sub-system 34 Code System: Defines a set of concepts with a coherent meaning Code Display Definition ‣ SNOMED CT / LOINC ‣ NZULM / NZMT ‣ ICPC, MIMS + 100s more ‣ ICD-X+ ‣ A drug formulary ‣ Custom
  35. 35. Page 35 Terminology Sub-system 35 ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. Code System: Defines a set of concepts with a coherent meaning Code Display Definition Value Set: A selection of a set of codes for use in a particular context Selects
  36. 36. Page 36 Terminology Sub-system 36 ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. Code System: Defines a set of concepts with a coherent meaning Code Display Definition Value Set: A selection of a set of codes for use in a particular context Element Definition: Type and Value set reference Selects Binds ▸ Binding:  Connection between element and ValueSet  Strength determines if can change
  37. 37. Page 37 Terminology Sub-system 37 ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. Code System: Defines a set of concepts with a coherent meaning Code Display Definition Value Set: A selection of a set of codes for use in a particular context Element: code/ Coding/ CodeableConcept Element Definition: Type and Value set reference Selects Binds Refers to Conforms
  38. 38. Page 38 Terminology Sub-system 38 ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. Code System: Defines a set of concepts with a coherent meaning Code Display Definition Value Set: A selection of a set of codes for use in a particular context Element: code/ Coding/ CodeableConcept Element Definition: Type and Value set reference Selects Binds Refers to Conforms Definition Instance
  39. 39. Page 39 Terminology binding: Condition resource 39 ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. • a ValueSet binding in the spec…
  40. 40. Page 40 Canonical Urls / system • Certain resources – http://hl7.org/fhir/references.html#canonical-list • StructureDefinition – Profile and Extension Definition • ValueSet • CodeSystem – Element name is ‘url’ • Is really a URI – Globally unique • Eg Extension definition or profile url – A form of reference • Eg ValueSet to CodeSystem • Should resolve (usually) but not required to – Eg support registry
  41. 41. Page 41 Example of canonical url • ValueSet -> CodeSystem
  42. 42. Page 42 Demonstration http://conman.clinfhir.com/connectathon.html?event=nz  Add data to the resources in the resource graph
  43. 43. Page 43 Adapting FHIR to your needs: Profiling • Many different contexts in healthcare, but want a single set of Resources • The 80% rule • Need to be able to describe ‘usage of FHIR’ based on context • Allow for these usage statements to: – Authored in a structured manner – Published in a registry & Discoverable – Used as the basis for validation, code, report and UI generation. • Profiling adapts FHIR for specific scenarios – A Statement of Use 43® Health Level Seven and HL7 are registered trademarks of Health
  44. 44. Page 44 FHIR as a platform spec • Base on which profiles / IGs are created • ‘80%’ rule • Minimum required fields • Minimum ‘required’ bindings Base Spec Profiling Customized Spec Eg IPS
  45. 45. Page 45 More on Profiling • 3 main aspects: – Constraining a resource - remove element, change multiplicity fix values – Change coded element binding – Adding a new element (an extension) • Modifier Extensions • Each profile has a unique (canonical) url – Represent as StructureDefinition resource • Package multiple profiles as Implementation Guide – Along with other artifacts (ValueSets, ConceptMaps etc.) 45® Health Level Seven and HL7 are registered trademarks of Health
  46. 46. Page 46 Example: Profile on a Patient Limit names to just 1 (instead of 0..*) Change maritalStatus to another set of codes that extends the one from HL7 international Specify that the identifier uses the NHI – and is required Don’t support photo Add an extension to support ethnicity
  47. 47. Page 47 Profiling in (more) depth • Conformance resources – StructureDefinition • Profile • Extension definitions • Conformance registries – FHIR server • Terminology – ValueSets, CodeSystems, NamingSystem
  48. 48. Page 48 Extensions • Extensions are normal – Can occur at many levels in resource instance • Same capabilities as core • ‘Levels’ and reuse – Core, National, Regional, Local • Extension Definition – (StructureDefinition) • Canonical Url in definition • Resource instance includes that Url – Therefore client can locate definition • Registry of extension definitions 48 ® Health Level Seven and HL7
  49. 49. Page 49 Extension in an instance <valueStringvalue=“jedi”/>
  50. 50. Page 51 Extensions: Examples • Simple • Complex
  51. 51. Page 52 Implementation Guide (IG) • All the artifacts for a particular business need – Outcome of profiling • For an implementer • Can be balloted by HL7 • Examples – US Core – Argonaut – IPS – QI-Core – CCDA on FHIR – Da Vinci (multiple) – Provider directory 52® Health Level Seven and HL7 are registered trademarks of Health http://www.fhir.org/guides/regis
  52. 52. Page 53 IG: General considerations • Must Support • Tooling – Forge (https://fhir.furore.com/forge/ ) – Simplifier Registry (https://registry.fhir.org/) – clinFHIR / conMAN (clinfhir.com) • Governance 53® Health Level Seven and HL7 are registered trademarks of Health
  53. 53. Page 54 Demonstration 54 ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. http://hl7.org/fhir/uv/ips/2019Sep/ International Patient Summary
  54. 54. Page 55 Implementer support • Development – Libraries • .net, java, python, swift, javascript – Reference servers • On-line, downloadable (http://hl7.org/fhir/downloads.html) – Validation • $validate operation • Java library – FHIR (zulip) chat • Design – clinFHIR Logical Modeler – conMan Graph Builder
  55. 55. Page 56 .net – update a patient
  56. 56. Page 57 .net – get extensions
  57. 57. Page 59 clinFHIR Logical Modeler • Graphical tool to build model using FHIR datatypes • 2 model types: – Pure information (eg Adverse Reactions) • Collect and document data from clinicians • Can review and publish as HISO information standard – Resource based (eg NHI / HPI) • To generate FHIR artifacts for Implementation Guide – Eg profiles – Can follow Information model • Review and publish in conjunction with HL7 NZ
  58. 58. Page 60 Demonstration • Creating a resource model to inform a profile – (Exercise 1 uses the Logical modeler) 60
  59. 59. Page 61 Exercises • https://docs.google.com/document/d/18pns_rXOjzgSBHM4 Fi7nXc54BWrpY94PWy7kVbYxty0/edit# • http://bit.ly/2PhBZHN
  60. 60. Page 62 Exchange Paradigms 62 ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. REST Documents Messages Services (Operations)
  61. 61. Page 63 Bundles • Container resource • Types of Bundle – Searchset – Transaction – Document – Message – … • Inherit from Resource – No text or extensions 63® Health Level Seven and HL7 are registered trademarks of Health Bundle Resource Patient Resource List Resource Condition Resource
  62. 62. Page 64 Exchange paradigm: REST • Preferred paradigm – Can be async • Searching – Defined searches per resource • Can add others – Chaining – Parameters (eg _include) – Results in Bundle • Operations – For more complex interactions (still real-time) – Defined and Custom • Eg Terminology search, $validate – Parameters resource Server can support any subset
  63. 63. Page 65 When to use REST? • Want low coupling between systems – In theory, very little up-front negotiation required • Small, light-weight exchanges • Focus is CRUD operations – Also for publish/subscribe • Client-driven client-server orchestration • Server endpoint has fixed location • Well-suited for Mobile, PHR, Registries 65
  64. 64. Page 66 When to avoid REST? • Complex or server-driven orchestration – Order of operations matters (e.g. complex decision support) • Unit of work != resource – “Transaction” may be an option • No natural “server” or no fixed network location • Lack of trust in the client for contextual audit, etc. 66
  65. 65. Page 67 Locating a single resource… http://server.org/FHIR/Patient/1 base path resource type id Not the same as a resource identifier
  66. 66. Page 69 Business identifiers • Id is not the same as a business identifier – Eg a Medical Records Number – Eg Patient.identifier, Encounter.identifier • Id is ‘structural’ – depends on server • Identifier is a resource property. – Same if a resource is moved 69
  67. 67. Page 70 Specify format URL: GET [server]/fhir/Patient/1?_format=json Response: HTTP/1.1 200 OK Response headers: Content-Type: application/json+fhir;charset=utf-8 Content-Length: 787 URL: GET [server]/fhir/Patient/1 HTTP/1.1 Request header: accept: application/fhir+json Response: HTTP/1.1 200 OK Response headers: Content-Type: application/json+fhir;charset=utf-8 Content-Length: 787
  68. 68. Page 71 CRU(P)D: Mapping to verbs create The create interaction creates a new resource in a server assigned location. The create interaction is performed by an HTTP POST operation as shown: POST [base]/[resourcetype] (?_format=mimeType) read The read interaction accesses the current contents of a resource. The interaction is performed by an HTTP GET operation as shown: GET [base]/[resourcetype]/{id} (?_format=mimeType) update The update interaction creates a new current version for an existing resource or creates a new resource if no resource already exists for the given id. The update interaction is performed by an HTTP PUT operation as shown: PUT [base]/[resourcetype]/{id} (?_format=mimeType) patch The patch interaction updates an exiting resource by supplying a document with the list of changes to apply. The document can be Json, XML or FHIR Path. The interaction is performed by an HTTP PATCH operation as shown: PATCH [base]/[resourcetype]/{id} delete The delete interaction removes an existing resource. The interaction is performed by an HTTP DELETE operation as shown (note logical delete & versioning): DELETE [base]/[resourcetype]/{id}
  69. 69. Page 72 Versioning • FHIR defines an API for managing changes – Optional • Previous versions can be listed / returned – At resource level • Delete is a ‘marker’ in the history – Can re-animate with a PUT to the same location • Resource history – GET [base]/[type]/[id]/_history • Get a specific version – GET [base]/[type]/[id]/_history/3 – Version not necessarily a number
  70. 70. Page 73 REST SEARCHING http://hl7.org/fhir/search.html 73
  71. 71. Page 74 Standard parameters • Each resource has a set of “standard” search operations, so not every element can be searched – Search name not always same as element name • Can define custom ones – SearchParameter resource
  72. 72. Page 75 Executing queries • POSTMan - https://www.getpostman.com/ • Server declares support in CapabilityStatement – GET [host]/metadata – http://hl7.org/fhir/http.html#capabilities • Returns a Bundle – Watch out for paging • _count parameter • Reference database really helpful – I use hapi (http://fhirtest.uhn.ca/baseR4/) • clinFHIR to create sample data – Patient Viewer -> Select Patient ? Add new patient – Much more at synthea - https://github.com/synthetichealth/synthea • Examples http://snapp.clinfhir.com:8081/baseDstu3/Patient?name=hay 75
  73. 73. Page 76 Combining parameters • Can search by GET & POST • Multiple parameters – Specifying multiple parameters finds resources matching all params  “AND” http://snapp.clinfhir.com:8081/baseDstu3/Patient?name=hay&gender=male – Parameters may list multiple values  “OR” http://snapp.clinfhir.com:8081/baseDstu3/Patient?name=smith,hay
  74. 74. Page 77 Summary of common parameters
  75. 75. Page 78 Chained searches • Search based on referenced properties – http://hl7.org/fhir/search.html#chaining • eg – Observations for a patient • Observation has a search for “subject” (the id of the Patient, Group or Device) • Patient has a search for “name” and “identifier”. • ‘chained’ search: – [host]/Observation?subject.name={x} – [host]/Observation?subject.identifier={y} • But note: this still only works on the predefined search parameters. You cannot just use any property of the resource. http://snapp.clinfhir.com:8081/baseDstu3/Observation?subject.name=hay
  76. 76. Page 79 Reverse Chaining • Selecting resources based on the properties of resources that refer to them – http://hl7.org/fhir/search.html#has • Return patients that have an Observation with a code of 9279-1 79 http://snapp.clinfhir.com:8081/baseDstu3/Patient?_has:Observation:patient:code=92 Particularly useful when using Proven Return a patient ‘search’ property on Observation Observation code Observations that reference the patient
  77. 77. Page 80 _Include related resources • Include related resources in the response • Based on search parameters • Server declares in conformance • Format – [host]/{type}?_include={source type}:{search parameter}:{target type} • Eg – [host]/MedicationOrder?_include=MedicationOrder:patient&criteria... http://snapp.clinfhir.com:8081/baseDstu3/Observation?_id=7294&_include=Observation:patient http://snapp.clinfhir.com:8081/baseDstu3/Observation?code=http://loinc.org|8310- 5&_include=Observation:patient
  78. 78. Page 81 Conditionals • Perform an operation if conditions met – Based on search parameters • Conditional Read – ‘If-modified-since’ header • Conditional Create – HTTP header – If-None-Exist: [search parameters] • Conditional Update – PUT [base]/[type]?[search parameters] • Conditional Delete – DELETE [base]/[type]/?[search parameters] https://fhirblog.com/2019/03/25/importing-csv-data-into-a-fhir-server/
  79. 79. Page 82 Custom queries • Use SearchParameter to define – http://hl7.org/fhir/searchparameter.html • Useful for searches on extensions • Like custom operations, does raise the interoperability bar
  80. 80. Page 83 Compartment • Syntactic sugar for queries • Resources that share common property – Eg patient • Purpose: – Access mechanism for finding a set of related resources quickly – Provide a definitional basis for applying access control to resources quickly • http://hl7.org/fhir/compartmentdefinition.html • Eg – http://snapp.clinfhir.com:8081/baseDstu3/Patient/7268/$everything
  81. 81. Page 84 $match • Defined operation for EMPI searching • Send partial Patient resource – Elements to match filled in • POST to “Patient” endpoint on server – Server applies business rules then (potentially) runs query • Response is bundle of matching patients with score { "resourceType":"Patient", "name":[{"family":"Doe"}], "birthDate":"1987-03-12", "gender":"male” }
  82. 82. Page 85 GraphQL • Allows queries to specify ‘shape’ to return – Generally REST returns whole resource – Though note _elements and _summary modifier • Can operate on single resource or at the ‘system’ level • Mostly query – Update not well defined • http://hl7.org/fhir/graphql.html http://test.fhir.org/r3/Patient/example/$graphql? query={name(use:official){text,given,family}}
  83. 83. Page 86 Updating patterns • Resource PUT – Replace the entire resource • Patch – The patch document • Operations – User defined update operations
  84. 84. Page 87 Resource PUT • Submit an updated resource • Client is in control (mostly) • Server – Doesn’t have to support – Can apply business logic / security to call
  85. 85. Page 88 Validating first… • Knowing the resource is valid – Actually, ‘conformant’ is the preferred term – Must be conformant to the core spec, additionally other profiles • Validation code from the community • $validate operation – Most reference servers support • http://hl7.org/fhir/validation.html 88
  86. 86. Page 90 Operations example • Operations hide complexity – Some in spec, can defined custom • OperationDefinition resource to define • Parameters resource – Enclose input data – Return result • Custom operations are a barrier to global interoperability – Not consistent across implementations https://fhirblog.com/2019/07/09/thoughts-about-updating-registries/ https://ontoserver.csiro.au/stu3-latest/ValueSet/$expand ?url=http://hl7.org/fhir/ValueSet/condition-code&filter=asthma
  87. 87. Page 91 Parameters resource • Use Parameters resource to pass parameters { "resourceType":"Parameters", "parameter":[ {"name":"nhi","valueIdentifier": {"system":"https://standards.digital.health.nz/id/nhi", "value":"XXX1234"} }, {"name":"address","valueAddress": {"use":"home","text":"23 Thule Street "} } ] }
  88. 88. Page 92 Using a Library
  89. 89. Page 93 PATCH example • Update part of a resource • Patch document – Specify changes to make – JSON, XML, FHIRPath • PATCH [base]/[type]/[id] {?_format=[mime-type]} • (Careful with arrays) http://hl7.org/fhir/http.html#patch https://fhirblog.com/2019/08/13/updating-a-resource-using-patch/ [{ "op": "add", "path": "/gender", "value": "female" }]
  90. 90. Page 94 Transactions & Batches • Same principle as Db transactions – POST a Bundle to server root • Transaction – Succeed / Fail as a unit • Batch – Partial update • http://hl7.org/fhir/http.html
  91. 91. Page 95 DOCUMENTS AND MESSAGES 95
  92. 92. Page 96 Document paradigm • Summary at a point in time • Part of record • Very common – Discharge Summary – Referral letter – Progress Note • A collection of resources • Equivalent to CDA – CCDA on FHIR 96® Health Level Seven and HL7 are registered trademarks of Health Patient Practitioner Observation Resource Device List Condition Composition • Subject • Author • Section:Obs • Section:Probs List Condition Bundle Note: Most resources have a reference to Patient https://chat.fhir.org/#narrow/stream/179273-CCDA-.2F.20FHIR.20mapping.20stream
  93. 93. Page 97 Composition resource • Document header – Document type – References to Patient, Author, Custodian … – Equivalent to: • CDA header • IHE XDS metadata • Sections (headings) – Contents are text and structured/coded data • Rules for rendering • Can be profiled (i.e. specific document types) 97® Health Level Seven and HL7 are registered trademarks of Health
  94. 94. Page 98 Messaging • Similar to v2 and v3 messaging • Also a collection of resources as a Bundle resource • Allows request/response behavior with bundles for both request and response • Event-driven • Needs agreement between parties – Tight coupling • E.g. Send lab order, get back result • Can be asynchronous and/or indirect
  95. 95. Page 99 Conversion between v2 & FHIR • Often replaced by REST – (REST wasn’t an option until recently) – Eg instead of ADT message, POST Patient resource to Lab server • Conversion ‘reasonably’ straightforward – Quite a few nuances though • HL7 working on mapping advice • https://chat.fhir.org/#narrow/stream/179188-v2-to.20FHIR
  96. 96. Page 100 FHIR AND THE MOH (Adapted from a HISO presentation)
  97. 97. Page 101 Current NZ projects • Adverse Reactions – Improve collection of Adverse Reaction data – Information model ready for comment • FHIR interface for NHI / HPI – Draft models created for phase 1 • Practitioner, PractitionerRole, Organization, Location – Plan to release test API asap – phase 2 will add services and careteams • Medication query API against NZULM – Support new users (ULM is complicated) – Support new functionality (future phase) • Bulk download for local caches • Decision support • CDS-hooks for EHR integration – Plan to release test API asap
  98. 98. Page 102 HPI Graph (phase 1)
  99. 99. Page 103 Development Process 1. Confirm requirements 2. Setup Test server & project app – http://nz.clinfhir.com/ – Currently standard FHIR server (HAPI) 3. Use clinFHIR Logical Modeler to build information models – Use conMan to build resource graphs where useful – Examples 4. Review models – HISO document based process at the moment – https://chat.fhir.org/#narrow/stream/179178-new-zealand 5. Build FHIR artifacts from models & publish in IG – Extension definitions automatically – Profiles combination manual / automatic – ValueSets & CodeSystems manual – Searches, queries, other technical stuff – FHIR IG publisher to generate IG 6. Technical review / ballot – With HL7 NZ – details TBD. 2 stage review as technical review is specialized. Separate business & technical aspects
  100. 100. Page 104 FHIR Community Process (FCP) • Proposed process for building FHIR Implementation Guides – Minimize overlap between IGs – Encourage/support community development – HL7 membership encouraged – not required • Co-ordination committee – Clearing House, not veto • Each project: – Documented governance process for IG development – Description, License, Maintenance Plan, Realm • https://wiki.hl7.org/index.php?title=FHIR_Community_Process
  101. 101. Page 105 clinFHIR Logical Modeler (redux) • Graphical tool to build model using FHIR datatypes • 2 model types: – Pure information (eg Adverse Reactions) • Collect and document data from clinicians • Can review and publish as HISO information standard – Resource based (eg NHI / HPI) • To generate FHIR artifacts for Implementation Guide – Eg profiles – Can follow Information model • Review and publish in conjunction with HL7 NZ
  102. 102. Page 106 Adverse reactions (Information Model)
  103. 103. Page 107 CSIRO: (Information Model)
  104. 104. Page 108 NHI (single resource)
  105. 105. Page 109 Once it’s in a model: We can generate different views /quality reports
  106. 106. Page 110 Analysis: ValueSets list
  107. 107. Page 111 Analysis: Extensions
  108. 108. Page 112 Generate document
  109. 109. Page 113 Tracking comments
  110. 110. Page 114 Security • FHIR is not a security standard, but… • Existing privacy well aligned with GDPR – (https://healthcaresecprivacy.blogspot.co.uk/2015/04/privacy- principles.html) • Current FHIR support: – AuditEvent, Provenance, Consent – Any resource has security tags – Authentication/Authorization • SMART on FHIR, Pages in spec – Identity resources • Patient, RelatedPerson, Practitioner, Organization & others… • Some gaps and areas for improvement – White paper to come 114® Health Level Seven and HL7 are registered trademarks of Health
  111. 111. Page 115 Blockchain • Technology behind bitcoin • Distributed list of transactions (blocks) • Cryptographically signed – Can’t change without detection • What is relationship with FHIR? – Unlikely actual clinical data – Tamper proof audit records – Provider Authentication – Supply chain (eg medication provenance) 115® Health Level Seven and HL7 are registered trademarks of Health
  112. 112. Page 116 SMART • Substitutable Medical Applications, Reusable Technologies – http://hl7.org/fhir/smart-app-launch/ • History • Originally limited to EHR external apps – Becoming the ‘de-facto’ Authentication • 2 aspects – App launching • Public & confidential – Authentication ‘Profile’ on OAuth2 & OpenID Connect • Endpoints and scopes • Sandbox: https://sandbox.smarthealthit.org/#/start • App Gallery: https://apps.smarthealthit.org/ 116® Health Level Seven and HL7 are registered trademarks of Health
  113. 113. Page 117 Oauth2 App Resource Server Authz Server 1. Delegate Authorization 3. Use App 4. Authenticate and Grant access 5. Issue code 7. Access resource (with token) 2. Application is registered with Auth server 6. Request access token (+refresh token) Repeat step 6 when access token expires
  114. 114. Page 118 Ecosystem • An ecosystem really needs one, shared Auth server – Most implementations combine Auth & Data servers • For this to work, more standards will help – Dynamic Client Registration (RFC 7591) – Token introspection (RFC 7662) – Server discovery (RFC 5785) • More granular scopes • Common Consent models • Standardized auditing – So consumer can see who accessed their data More data: bit.ly/smart-fhir-tech
  115. 115. Page 119 CDS Hooks • Clinical Decision Support (CDS) – User Interface for display CDS – ‘hooks’ to EHR activity • Service can call back to EHR – Or any other data store • Discovery & endpoints • Prefetch • Security Model – ‘out of band’ setup • Key exchange – TLS – Encrypted JWT in call to service – Access token provided for call back 119® Health Level Seven and HL7 are registered trademarks of Health http://cds-hooks.org/specification/1.0/ https://chat.fhir.org/#narrow/stream/179159-cds-hooks
  116. 116. Page 120 Bulk Data • Population level data – Multiple patients – Large data sets • Define operations – $export / $import – ndjson as format • Asynchronous operation • SMART as security • Still in development • http://hl7.org/fhir/uv/bulkdata/STU1/ • https://chat.fhir.org/#narrow/stream/179250-bulk-data
  117. 117. Page 121 Decision Support • Clinical Reasoning module • 2 main use cases – Sharing knowledge artifacts – Evaluating knowledge artifacts in the context of a population • Decision Support, Quality measures • A complex area! • http://hl7.org/fhir/clinicalreasoning-module.html • https://chat.fhir.org/#narrow/stream/179220-cql
  118. 118. Page 122 WorkFlow • Eg Referral, tracking orders • Resource characteristics – Request • Eg MedicationRequest – Event • Eg MedicationDispense – Definition – Eg PlanDefinition • Task Resource – As a ‘tracker’
  119. 119. Page 123 Reality check • Sounds wonderful! • Managing Expectations • Analogy of building house – All this is the concept plan… • What does FHIR really stand for? Far Harder In Real life! ® Health Level Seven and HL7 are registered trademarks of Health123
  120. 120. Page 124 More information • From HL7 – http://hl7.org/fhir/index.html – wiki.hl7.org/index.php?title=FHIR • Community – http://www.fhir.org/ – https://chat.fhir.org/ – List server (fhir@lists.hl7.org ) – Stack Overflow (tag FHIR) • Blogs – www.healthintersections.com.au/ – https://fhirblog.com/ – https://thefhirplace.com/ – https://brianpos.com • Libraries – Java (http://hapifhir.io/) – C# (NuGet HL7.FHIR)Tooling – Forge (http://fhir.furore.com/Forge) • 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 – https://fhirblog.com/2016/10/19/setting- up-your-own-fhir-server-for-profiling/ ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. 124
  121. 121. Page 125 That’s it! ® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office. 1

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