This document discusses various topics related to health data standards and interoperability. It provides an overview of SMART on FHIR, which uses HL7 FHIR and OAuth 2.0 to allow third-party applications to safely and securely access patient data from electronic health records and other healthcare IT systems. It also discusses FHIR Questionnaires and how they can be used to capture structured data from forms and questionnaires. Finally, it briefly introduces the Device Observation profile for representing device-generated observational health data using the FHIR Observation resource.

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Access to health
data
Ewout Kramer
FHIR Core team (and software developer)
Furore (Amsterdam, NL)
email: e.kramer@furore.com
web: http://thefhirplace.com
http://fhir.furore.com
skype: 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
3
“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!
6

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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 significant 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 Technology
Lars Kristian Roland, Architect at the Norwegian Directorate of eHealth; Johan Eltes, Deputy CTO Inera AB, Thor Schliemann, Architect at
the Danish Health Data Authority.
11

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SMART ON FHIR
Integrating in the EMR
12

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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
14

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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 + …
17

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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
20

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Additional constraints
21

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App Gallery
22

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Growth analyzer
23

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Run a demo…

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Launch context

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CDS-Hooks
28
EMR
Medication-
prescribe
Order-review
Patient-view
Events in the
EMR
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
32

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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
34

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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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36
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)37

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Questionnaire model
38
Linkid: ties questionnaire
and response
Required: yes/no
Repeats: yes/no
status: Is this questionnaire still active?
date: When did this status become effective
subjectType: 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
39

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QuestionnaireResponse
40
Author, source and subject!
Here’s linkId again!
Answer can point to a real Resource!

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Example Questionnaire /
Response workflow
41

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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+Captu
re+Initiative
 http://hl7.org/fhir/sdc/sdc.html
43

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Render-a-Questionnaire
 http://smartq.azurewebsites.net/Home/Select
Survey
44

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C3-PRO + ResearchKit
45 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!46

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DEVICE OBSERVATION –
A PROFILE
47

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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
49

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Example instance
 http://spark.furore.com/fhir/Observation/satO
2?_format=xml
 http://hl7.org/fhir/observation-example-
satO2.html
 Take a look at the xml!
50

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Continua WAN
51
Uses IEEE 11073 and IHE-PCD
Profile
Semantically equivalent to
FHIR 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)
52

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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)
53

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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…
54

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PATIENT ACCESS OR
PATIENT IN THE CENTER?
55

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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…
57

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Apple ResearchKit
59

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Where is the Portal?
PHR?

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Reality?
61

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Reality?
62

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FINALLY…
63

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64
 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