Fhir documents - Lloyd McKenzie

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FHIR Documents

Lloyd McKenzieFHIR Developer DaysNovember 19th, 2015


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Who am I?

Name: Lloyd McKenzie Company: Gevity Background:

One of FHIR’s 3 principle editors Co-chair FMG, FHIR Infrastructure Co-chair HL7 Modeling & Methodology Heavily involved in HL7 and healthcare exchange

for last 15 years (v2, v3, CDA, etc.)


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WHERE DO DOCUMENTS FIT?


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Paradigms

FHIR supports 4 interoperability paradigms

RESTDocuments

Messages Services


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Documents

Similar to CDA Collection of resources bound together

Root is a “Composition” resource Just like CDA header

Sent as a bundle One context Can be signed, authenticated, etc.

Documents


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When to use Documents? Focus is on persistence No workflow involved

other than post/retrieve document Need tight rules over authenticated content Want to communicate multiple resources

with control over how data is presented Data spans multiple resources

Documents


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When to avoid Documents? Need for workflow

Request/response, decision support Data is dynamic

I.e. want view of data now, not at time of authorship

Multiple contributors over time Resources need to be accessed/manipulated

independently

Documents


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Clinical Documents

6 Characteristics Persistence Stewardship Potential for authentication Context Wholeness Human readability


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Non-clinical documents

FHIR documents are a generic structure Can be about anyone/anything

E.g. Trial designs, device reports, public health studies, etc.

Can be processed in ways that don’t meet the 6 requirements for a clinical document


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DOCUMENT STRUCTURE

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Discharge Medslist

Vital Signslist

Kidney StonesCondition

Patient MaryPatient

Dr. BernardPractitioner

content

content

content

subject

author

DyclofenacMedicationPrescription

TamsulosinMedicationPrescription

entry

PulseObservation

BPObservation

entry

Nurse SmithPractitioner

DischargeSummary

Composition

Chief Complaint

section

Physicalsection

Medicationssection

FHIR Document


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Discharge Medslistcontent

Vital Signslistcontent

Kidney StonesConditioncontent

Patient MaryPatientsubject

Dr. BernardPractitionerauthor

DyclofenacMedicationPrescription

TamsulosinMedicationPrescription

entry

PulseObservation

BPObservation

entry

Nurse SmithPractitioner

DischargeSummary

Composition

Chief Complaint

section

Physicalsection

Medicationssection

FHIR Document


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Documents – are bundles

Observation Resource

Composition Resource

Section

Device Resource

Condition Resource

List Resource

<Bundle> <entry> <Composition /> </entry> <entry> <Observation /> </entry> <entry> <Device /> </entry> <entry> <List/> </entry> <entry> <Condition/> </entry></Bundle>

AttesterMetadata Section

Section


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The Composition resource


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Tag as “Document”

This Bundle is a Document


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Bundle References

References in bundles can be: Absolute: e.g. http://hl7.org/fhir/Patient/1 Relative: e.g. Patient/1

Relative is expressed with respect to the URL of the referencing resource

Non-RESTful ids In some cases, a resource might not exist on a

RESTful server Solution: entry base = “urn:oid” or “urn:uuid” Resource identifier is an OID or a UUID

http://hl7.org/fhir/Patient/1


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COMMUNICATING FHIR DOCUMENTS

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Communicating documents You can store your document using

https://server.org/fhir/Bundle Storage, NO disassembly is implied,

document (and signature) stays intact Search is supported (you search on it using

Composition search criteria)


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Communicating documents (cont’d) Documents can be passed around using the

Binary resource https://server.org/fhir/Binary

Storage, NO disassembly is implied, document (and signature) stays intact

Search is supported, but only by id Useful for referencing a document as a

resource


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Communicating documents (cont’d) Documents can be sent to a server’s “root”

URI for processing as a transaction https://server.org/fhir

Each resource is processed separately Document id and signature is lost Can theoretically re-assemble by retracing

from the Composition resource


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Communicating documents (cont’d) You can pass a document as a parameter to

an operation Behavior depends on the definition of the

operation, but could include workflow invocation, persistence, disassembly, generation of DocumentReference instances or combinations there-of


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DocumentReference

Doesn’t actually store the document, just a reference to it

Useful in “shared index” models such as MHD (XDS on FHIR)

The DocumentReference can then point to the document itself – at either the Document/Bundle end-point or the Binary endpoint.


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Custom operations

The OperationDefinition resource allows you to define custom operations Take arbitrary data types, resource references and

bundles (e.g. Documents) as parameters Allows you to define behavior around

communicating documents. E.g. Request a referral to be “processed” by

submitting a referral document


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Is that all?

Nope - Documents can be shared any way you like Email (secure if you’re sharing patient data!) FTP (ditto) SOAP Memory stick/DVD by courier Smoke signals . . .

FHIR defines the HTTP end-points as conveniences, not to mandate a transport solution.


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FHIR DOCUMENT ARCHITECTURE CONSIDERATIONS

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Document Profiles

Documents are most useful when you can define standard structures and content for them E.g. CCDA, Oncology referral for hospital X

Profile resource allows Defining the structure of the Composition

Slicing section for each section content Defining the structure of all referenced resources Identifying which resources must be/can be

included in the document bundle


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Section Slicing


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Document persistence

There is no defined order to entries in a document other than the first Round-tripping between persistence and XML/

JSON (or RDF) may produce different orders Even with canonicalization, signatures may not

hold if document elements are stored in their constituent parts

Therefore: If you care about signature, store documents as a

binary


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Document Signatures

Any bundle (including Documents) can have an XML digital signature Signatures aren’t required to use FHIR documents

– other means of verifying integrity, etc. are ok too One or more resources in a document can

also be signed by including a Provenance resource.


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Tags and security

Tags (and ‘security’ metadata) can appear on both resource entries and at the bundle level If using security tags, must establish precedence

Safest is ‘most restrictive applies’, but business rules may differ

Tags inside document entries can’t be changed without breaking the document signature


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FHIR DOCUMENTS & THE STANDARDS SPACE

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Mobile Health Data

IHE specification that leverages FHIR to implement XDS

Can index FHIR documents or any other For that matter, XDS can index FHIR documents

too . . .

IHE Concept FHIR Resource

DocumentEntry DocumentReference

SubmissionSet DocumentManifest

Folder List


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CDA on FHIR

Project to define what “clinical documents” should look like in FHIR

Will include Profile of the Composition resource Mapping of CDA header to Composition High-level mapping of root entries to possible

corresponding


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CCDA on FHIR

Project to map between CCDA and a FHIR-equivalent, including profiles

Long term vision is a new version of CCDA with exact FHIR equivalents balloted in parallel


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CDA <-> FHIR

Some guidance can be found here: http://hl7.org/fhir/comparison-cda.html

http://hl7.org/fhir/comparison-cda.html

http://hl7.org/fhir/comparison-cda.html


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Questions?

http://hl7.org/fhir [email protected]

http://hl7.org/fhir

mailto:[email protected]

Healthcare

Fhir documents - Lloyd McKenzie