A deeper dive into how FHIR will enable the NZ EHR

1. A DEEPER DIVE INTO
HL7 FHIR
DAVID HAY | JULY 2016

2. Page 2 • 2016 © Orion Health™ group of companies
DR. DAVID HAY
Medical 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

4. 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
General
AllergyIntolerance
Condition (Problem)
Procedure
ClinicalImpression
FamilyMemberHistory
RiskAssessment
DetectedIssue
Care Provision
CarePlan
Goal
ReferralRequest
ProcedureRequest
NutritionOrder
VisionPrescription
Medication &
Immunization
Medication
MedicationOrder
MedicationAdministration
MedicationDispense
MedicationStatement
Immunization
ImmunizationRecommendation
Diagnostics
Observation
DiagnosticReport
DiagnosticOrder
Specimen
BodySite
ImagingStudy
Clinical
http://hl7.org/fhir/resourcelist.html

7. 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 id
oid
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 resources
Coded Properties
type
bodySuite
indication
performer.role
complication
relatedItem.type
Standard Properties
identifier (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
Code
Display
Definition

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Terminology Sub-system
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

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Terminology Sub-system
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 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
Code
Display
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

19. 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
FHIR
Repository
National Exchange
FHIR
Document

25. PROFILES
20

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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

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▸ 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 (fhir@lists.hl7.org )
– 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=Public
ly_Available_FHIR_Servers_for_testing
▸ White papers – http://orionhealth.com
– FHIR - Sparking innovation in health
information sharing
– FHIR – Ignites healthcare sharing
More information

34. 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