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

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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

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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=Publicly_Available_FHIR_Servers_for_testing

▸ White papers – http://orionhealth.com– FHIR - Sparking innovation in health

information sharing– FHIR – Ignites healthcare sharing

More information

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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