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Dr. David Hay
▸ Medical Doctor▸ Chair emeritus of HL7 New Zealand▸ Co-chair FHIR Management Group▸ Product Strategist Orion Health▸ Blog: fhirblog.com▸ Tooling: clinFHIR.com
▸ Email: [email protected]
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Todays Agenda
▸ What is FHIR (and why do we need it)▸ Basics of FHIR
– Resources– Profiling– Exchange (especially REST)
▸ Associated Standards– Security– SMART– CDS Hooks
▸ More info▸ Goal is to make you want to look further!
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Why Interoperability?
▸ Health information sharing is important– Individuals involved in delivering care to patients now expect the
information they require to be available at the point of care▸ Data collected in multiple places
– Realistically need to move information around▸ Need to involve patients in care▸ Interfaces are expensive
– Especially if not standards based
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Why FHIR?
In 2011, the Board of HL7 noted:
‣ Interoperability requirements are increasing‣ Need for real time access (API)
- Mobile‣ Vast increase in the amount, type and source of data
- e.g. Devices, Genomics‣ Analytics, population health‣ Implementer expectations
Existing standards were lacking, a fresh look was needed…
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Overview of FHIR
▸ Fast Healthcare Interoperability Resources (FHIR)▸ Consistent, simple to use content model (resources)
– Controlled extensibility▸ Supports all paradigms of exchange
– Well thought out, standardized APIs– Documents & Messages
▸ Designed with implementers in mind▸ Detailed on-line, hyperlinked specification▸ Strong endorsement and support from vendors, providers
and regulatory community ▸ Vast, International community
http://hl7.org/fhir/index.html
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Advantages for Implementers and Vendors
▸ Familiar tooling and technologies– XML/JSON, HTTP, REST, SSL, OAuth2
▸ Predefined resources and APIs – Domain knowledge is not required– Allows implementer to focus on the core application functionality
▸ Extensive on-line documentation, examples and reference server implementations▸ Open Source code libraries
– HAPI (Java) and Furore (.Net)▸ Test servers▸ Mobile friendly▸ Active and supportive community
Increases commercial viability of app development as FHIR compliant apps will work with different FHIR Servers (EMRs, HIEs)
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FHIR timeline
2012 20162014 2018 2020
FirstDraft
2011 20152013 2017 2019
1st
DSTU2nd
STU~ 1st
Norm.~ 2nd
Norm.. . .
FreshLook
3rd
STU
FMM
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1. Content: Scope of specification - hl7.org/FHIR. (http://build.fhir.org/)
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Resources: what are they?
▸ The content model▸ The Thing that is exchanged
– Via REST ( FHIR Restful API), Messages, Documents
▸ Informed by much past work inside & outside of HL7– HL7: version 2, version 3 (RIM), CDA– Other SDO: openEHR, CIMI, ISO 13606, IHE, DICOM
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Clinical Resources
GeneralAllergyIntolerance
Condition (Problem)Procedure
ClinicalImpressionFamilyMemberHistory
RiskAssessmentDetectedIssue
Care ProvisionCarePlan
GoalReferralRequest
ProcedureRequestNutritionOrder
VisionPrescription
Medication & Immunization
MedicationMedicationOrder
MedicationAdministrationMedicationDispenseMedicationStatement
ImmunizationImmunizationRecommendation
DiagnosticsObservation
DiagnosticReportDiagnosticOrder
Specimen BodySite
ImagingStudy
Clinical
http://hl7.org/fhir/resourcelist.html
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The resource ‘type’ in the specification (http://hl7.org/fhir/patient.html)
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Resource example
Resource Identity & Metadata
Human Readable Summary
Extension with URL to definition
Standard Data:• MRN• Name• Gender• Birth Date• Provider
JSON also supported
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References between resources
Coded PropertiestypebodySuiteindicationperformer.rolecomplicationrelatedItem.type
Other Propertiesidentifier (Identifier)outcome (String)
PROCEDURE
PATIENT
DIAGNOSTIC REPORTCONDITION
Subject
ReportRelated Item
Encounter Performer
ENCOUNTER PRACTITIONER
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Recording a consultation
12-year-old-boy
First consultationComplaining of pain in the right ear for 3 days with an elevated temperature. On examination, temperature 100.4°F and an inflamed right eardrum with no perforation. Diagnosis Otitis Media, and prescribed Amoxicillin 250mg 3 times per day for 7 days.
Follow up consultation2 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 250mg 4 times per day for 10 days.
Patient
Encounter
Condition
Observation
Medication
Allergy Intolerance
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Encounter
Encounter
Practitioner
Patient
Asserter
Performer
Performer
Performer
Performer
Performer
Performer
Asserter
Asserter
Prescriber
Asserter
Pain right ear 3 days
Otitis media
Itchy skin rash
No breathing difficulties
Elevated temperature
Temperature 100.4°F
Inflamed right drum
Urticarial Rash
Amoxicillin 250mg
Erythromycin 250mg
Penicillin Allergy
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2. Adapting FHIR to your needs: 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▸ 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.
▸ 3 main aspects:– Constraining a resource - remove element, change multiplicity fix values– Change coded element binding– Adding a new element (an extension)
▸ Profiling adapts FHIR for specific scenarios
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Profiling a resource | for example…
Note: Limited mandatory elements in the core spec
Require that the identifier uses the medicare number – and is required
Limit names to just 1 (instead of 0..*)
Change maritalStatusto another set of codes that extends the one from HL7 international
Add an extension to support ethnicity
Don’t support photo
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3. Exchange: 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▸ Very commonly used outside of healthcare – especially mobile
– JASON report called out the lack of an API▸ For simple interactions
– Create– Read (& Query)– Update – Delete
▸ A lot of tooling / experience availablehttp://hl7.org/fhir/http.html
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Mapping to verbs
create 2.1.10 The create interaction creates a new resource in a server assigned location. The create interaction is performed by an HTTP POST operation as shown:
POST [service-url]/[resourcetype] (?_format=mimeType) read 2.1.6
The read interaction accesses the current contents of a resource. The interaction is performed by an HTTP GET operation as shown:
GET [service-url]/[resourcetype]/{id} (?_format=mimeType) update 2.1.8
The update interaction creates a new current version for an existing resource or creates a new resource if no resource already exists for the given id. The update interaction is performed by an HTTP PUT operation as shown:
PUT [service-url]/[resourcetype]/{id} (?_format=mimeType) delete 2.1.9
The delete interaction removes an existing resource. The interaction is performed by an HTTP DELETE operation as shown (note logical delete & versioning):
DELETE [service-url]/[resourcetype]/{id}
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More advanced API
▸ Version aware updates▸ Conditional create / update▸ Partial update▸ Batch / Transactions▸ Subscription▸ OperationOutcome resource▸ Search (http://hl7.org/fhir/search.html)
– Bundle resource– Search parameters
• combining parameters - and/or• chaining• _include• _query
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CapabilityStatement resource
▸ What can a server do:• Which FHIR version?• Which Resources?
• What operations against those resources?• What formats (XML/JSON)?• Is history supported?
• General Information• Who can I contact?• What’s the name of the software?
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Services / Operations
▸ For more complex server side logic– OperationDefinition
▸ Real-time or async▸ Key part of ecosystem▸ E.g.
– Prescribing with Decision Support– Terminology– Immunization protocols
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Regardless of paradigm, the content is the same
FHIRRepository
Document
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FHIR Security & Privacy
▸ Not part of core spec– Highly specialized– Much existing knowledge / systems– Many different environments
▸ Hooks– Security tags– Specific resources
• AuditEvent, Provenance, Consent▸ Recommendations
– http://www.hl7.org/implement/standards/fhir/security.html
– OAuth2 & SMART
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OAuth2: a high level
An example implementation
APP
1. AUTHENTICATE AND GETACCESS TOKEN
2. MAKE FHIR QUERYINCLUDING ACCESS TOKEN
RESOURCE SERVER
EHR
AUTHORIZATIONSERVER
DATABASES
3. CHECK TOKEN
0. ESTABLISH RELATIONSHIPS
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FHIR and SMART: enabling the ecosystem
FHIR API and Resources
Terminology
Registry Identity
Repository
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Clinical Decision Support | CDS Hooks (http://cds-hooks.org/)
Database
Request Advice
Return Suggestion
1
3
2More data
Application SMART/FHIRClinical Decision Support
CDS Services
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Learning FHIR: clinFHIR
▸ Developed as training tool▸ Evolving!▸ Main components
– Scenario Builder– Logical Modeler – CodeSystem Builder– ValueSet editor– Profile editor– Extension Definition editor
http://clinfhir.com
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When to start using FHIR
▸ Now!▸ Better than bespoke
– Even though not finished…▸ Build on decades (person centuries) of thought & experience▸ Already real world uses out there
– Australia– Lithuania– United States - Commonwell
▸ Access to community for advice– Contribute own experience
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In Summary
▸ FHIR is the latest HL7 interoperability standard▸ Promises to revolutionize sharing of healthcare information▸ Enormous interest locally and internationally▸ It future-proofs your IT investment▸ Is not a silver bullet▸ FHIR is disruptive▸ FHIR IS in your future
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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 ([email protected] )– 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
Rhapsody® Integration Engine is intended only for the electronic transfer, storage, or display of medical device data, or the electronic conversion of such data from one format to another in accordance with a preset specification as specified in the product manual and/or related documentation. Rhapsody Integration Engine is not intended to be used for active patient monitoring, controlling or altering the functions or parameters
of any medical device, or any other purpose relating to data obtained directly or indirectly from a medical device other than the transfer, storage, and conversion of such data from one format to another in accordance with preset specifications. Orion Health makes no warranties and the functionality described within may change without notice.
ONC Health IT Certification (2014 Edition) Rhapsody Integration Engine and Rhapsody Connect attained 2014 Edition Modular Ambulatory EHR Certification and 2014 Edition Modular Inpatient EHR Certification from the ICSA Labs ONC Health IT Certification Program. This EHR Module is 2014 Edition compliant and has been certified by an ONC-ACB in accordance with the applicable certification criteria adopted by the
Secretary of Health and Human Services. This certification does not represent an endorsement by the U.S. Department of Health and Human Services. For more information, please see Rhapsody® is a registered trademark of Orion Health™ Limited, manufactured in New Zealand, by Orion Health Limited. All other trademarks displayed in this document are the property of Orion Health or their respective owners, and may
not be used without written permission of the owner. Rhapsody Integration Engine is not intended to be used for diagnostic purposes, or to replace clinical judgment or responsibilities.All patient information shown in any imagery is for representation and demonstration purposes only and is not related to a real patient.
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