Vitalis 2016 FHIR App Development

Access to health data

Ewout KramerFHIR Core team (and software developer) Furore (Amsterdam, NL)

email: e.kramer@furore.comweb: http://thefhirplace.com

http://fhir.furore.comskype: ewoutkramer

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 ?

Personal Info Exchange

“In many ways this overlaps with the innovation framework labeled ‘SMART on FHIR’”

REST AND DOCUMENTS

“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

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!

Longitudinal data

Human/System interactions

Helse Vest Self booking Project

“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

“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 signifi cant 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!

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 TechnologyLars Kristian Roland, Architect at the Norwegian Directorate of e Health; Johan Eltes, Deputy CTO Inera AB, Thor Schliemann, Architect atthe Danish Health Data Authority.

SMART ON FHIRIntegrating in the EMR

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).

Motivation….

Turn bright ideas into real apps Take away the technology burdens

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)

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

SMART = FHIR + …

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)

SMART Authorization

Slightly simplified - details at: http://docs.smarthealthit.org/authorization/

Agree on actual codes

Additional constraints

App Gallery

Growth analyzer

Run a demo…

Launch context

CDS-HooksEMR

Medication-prescribe

Order-review

Patient-view

Events in theEMR

External services hooked to the events

Source: https://github.com/cds-hooks/cds-hooks/wiki

Live demo

Try: http://hooks.fhir.me/#"activity":"medication-prescribe"

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

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

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

FHIR QUESTIONNAIRES

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

Item/question

Item-group

Nested Item/question

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)

Questionnaire model

Linkid: ties questionnaire and responseRequired: yes/noRepeats: yes/no

status: Is this questionnaire still active?date: When did this status become effectivesubjectType: What must QuestionnaireResponse.subject be?concept: Code for the overall questionnaire

Nests!

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

QuestionnaireResponse

Author, source and subject!

Here’s linkId again!

Answer can point to a real Resource!

Example Questionnaire / Response workflow

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

Forms in apps US ‘Structured Data Capture’ (SDC) project

Pre-population of forms from CDA R2 data http://wiki.siframework.org/

Structured+Data+Capture+Initiative http://hl7.org/fhir/sdc/sdc.html

Render-a-Questionnaire

http://smartq.azurewebsites.net/Home/SelectSurvey

C3-PRO + ResearchKit

Source: http://c3-pro.chip.org/architecture.html

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!

DEVICE OBSERVATION – A PROFILE

The Observation

Points of Interest

Subject: the Patient and/or the Device

effective[x] and issued

Component versus Related

Device and DeviceMetric

Example instance

http://spark.furore.com/fhir/Observation/satO2?_format=xml

http://hl7.org/fhir/observation-example-satO2.html

Take a look at the xml!

Continua WAN

Uses IEEE 11073 and IHE-PCDProfile

Semantically equivalent toFHIR DeviceMetricObservation profile

(FHIR will be used in 2017 CDG WAN-IF?)

IEEE 11073 in FHIR

DeviceComponent Resource(any medical device that does not represent a metric, e.g. MDS, VMD, or Channel)

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)

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…

PATIENT ACCESS OR PATIENT IN THE CENTER?

Your “Mobile” device becomes the Big Aggregator and Coordinator of data and functionality

In the financial sector…

Apple ResearchKit

Where is the Portal? PHR?

Reality?

FINALLY…

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

Vitalis 2016 FHIR App Development

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Vitalis 2016 FHIR App Development