FHIR – the new currency and process of exchange
Dr. David HayChair HL7 New Zealand
Co-Chair FHIR Management GroupBoard Member HINZ
Member HISOInformation Architect, Orion Health
www.fhirblog.com
Page 2 • HL7 New Zealand
Agenda
• A review of FHIR
• Evolving the Interoperability Reference Architecture with a FHIR focus
• A practical example
• What we should be doing now
A review of FHIR
Page 4 • HL7 New Zealand
A brief history & current status
• Latest HL7 Interoperability Standard
• 2 years old
• Huge international interest– Vendors
– National Bodies
– Other SDOs
• Currently DSTU-1– DSTU-2 mid next year
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Use across all Paradigms
• Document– Discharge Summary
– Clinic Notes
– Ambulance summary
– Referral
• Message– Admin (‘ADT’)
– Lab results and orders
• REST– Mobile
– Real time access
• Service– Complex back end logic
– Decision support
REST
DocumentsMessages
Services
Same resources
across all paradigms
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REST
Client Server
Request
Response
HTTP/S
• HTTP– Verbs
– Headers
– Status Codes
• The way the web works…– Familiar to developers
– Lots of tools
• Examples:– Add (POST [server]/Patient)
– Retrieve (GET [server]/Patient/100)
– Update (PUT [server]/Patient/100)
– Search (GET [server]/Patient?name=eve)
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Resources
• “Resources” are:– A core part of FHIR
– Small logically discrete units of information
• Smallest unit “of interest” to healthcare
– Defined behaviour and meaning
– Known identity / location
• (usually)
• They’re the building blocks…
7
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Main Clinical resources
• Observation
• Condition (Problem)
• DiagnosticReport
• MedicationPrescription (and others)
• AdverseReaction / AllergyIntolerance
• Immunizations / ImmunizationRecommentation
• CarePlan
• Questionnaire / QuestionnireAnswers
• ReferralRequest
• ContraIndication
• RiskAssessment
• Assessment
• Alert
Page 9 • HL7 New Zealand
Important Supporting Resources
• Patient
• Practitioner
• List
• Encounter / EpisodeOfCare
• Order / OrderResponse
• DocumentReference
• Appointment / AppointmentResponse / Availability / Slot / HealthcareService
• Provenance
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ResourceNarrative
Elements
Extensions Extensions
Structure of a Resource
Metadata
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Resource as a bag of DataTypes
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References between resources
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Profiles
• Constrains a resource/s for a specific use case
• Where extension definitions are stored
• It’s a resource like any other– Can be queried/located like any other resource
– Profile registries easy
Resource Profile
Extension
The extension points to its profile
Can be (and probably are) on different servers
HTTP://server/Profile/nzpatient#iwi
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Other things about resources
• Collections (bundles)– Query result– Transactions– Documents– Messages
• Versioning• Tools
– XML Editor– REST client– Libraries– Test Servers
33, v12 – 2012-12-04
33, v13 – 2012-12-05
33, v14 – 2012-12-08
Patient/33/_history/12
Patient/33/_history/13
33, v15 – 2012-12-09
Patient/33/_history/14
Patient/33/_history/14
Patient/33
Evolving the IRA with a FHIR focus
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Interoperability Reference Architecture
XDSCDA Archetypes
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CDA as the unit of exchange
• Move to FHIR documents– Timing – next year earliest (DSTU-2)
– Continue with simple CDA for a while
• Migrate current CDA designs straight forward– Closed nature of our design
– Create FHIR profiles of current specs
• Modify GP2GP toolkit to support FHIR documents– FHIR document to/from object interface
– Our CDA to/from FHIR documents
– Support combined CDA/FHIR documents
• Ultimately resources are the units of exchange– Moving beyond documents
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XDS (Record Locator)
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Archetypes
• Formal descriptions of clinical practice– Wide clinical input
– Peer reviewed
– Sophisticated tooling
• Use profiles to map requirements to FHIR– As with CDA -> FHIR or v2 -> FHIR
• Emphasize importance of standardizing profiles– FHIR resources are engineering
– Profiles represent clinical perspective
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Transition considerations
• If it ain’t broke…– Leave existing v2 messaging for now
• Though transformation should be straightforward
• National– Need Record Locator Service
• But with a FHIR façade – not ebXML
• Use Document metadata standard
– Need other infrastructure
• Profile registry
• OAuth2 / OpenID connect (SMART)
• FHIR enabled repositories (with Consumer access)
– Eg MLOM, Allergies
• Local– FHIR enable local systems (query at least)
• Example of Brett’s work with PMS
– Toolkit
Moving into clinical records:A practical example
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Moving beyond exchange
• Resources as basis of storing clinical notes
• Theme:– A mobile application for a clinician
– Collect and present clinical information about a patient
• Previous encounters
• Lab Data
• Documents
– Record details of an encounter
– Schedule encounters
– Make orders for Labs, meds etc.
– Get Decision support
– Save a summary in a Document Repository
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The app
• Not considering:– Security
– App architecture
– Other infrastructure
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Clinical Scenario
• First consultation– Complaining of pain in the r) ear for 3 days with an
elevated temperature. On examination, temperature 38.5 degrees and an inflamed r) ear drum with no perforation. Diagnosis Otitis Media, and prescribed Amoxil 250mg TDS for 5 days
• Follow up consultation– 5 days later returned with an itchy skin rash. No
breathing difficulties. On examination, urticarial rash on both arms. No evidence meningitis. Diagnosis of penicillin allergy. Antibiotics changes to erythromycin and advised not to take penicillin in the future.
Condition
Observation
Med
Adv Rean.
Allergy
Encounter
5 year old boyPatient
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Looking at the relationships
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Creating a summary document
What should we be doing now
Page 30 • HL7 New Zealand
Practical next steps
• Form a local community– Multi-discipline
– FHIR is coming, it’s not ‘IF’ any more…
• Learn the specification– It’s very readable
– Play with the test servers
• Profiles and archetypes
• CDA to FHIR documents– The babelFish (toolkit)
– Design work
Thanks for listening!
• Stand up test services– Record Locator Service
– FHIR repositories
– Security infrastructure
– Profile registries
• Support innovation – and innovators– Clinicians Challenge version 2?
– Especially mobile