Interoperability, the rise of HL7, and FHIR

Suranga Nath Kasthurirathne

About myself…

• BEng in Software Engineering (Hons) 1st Class, University of Westminster , UK (2013)

• PhD (Health Informatics) at Indiana University – Purdue University (IUPUI) 2018 (Expected)

• Community Manager, (Asia-Pacific), OpenMRS• Google Summer of Code (GSOC) Co-

Organization Administrator for OpenMRS

My interests

• Clinical Decision Support (CDS)• Standards (HL7 and FHIR)• Health Information Architecture• Smart devices stuff• Being an ‘Early Adopter’ for OpenMRS• Anything else my boss wants me to do…

Disclaimers

What we will cover

• Interoperability AKA the problem domain• Standards from the HL7 family• FHIR• Comparison of existing standards• FHIR demo• “What if” situations

The existing landscape

• Healthcare quality is enabled by the accessibility and effective use of clinical data

• Clinical data is being collected across the globe in numerous ways

• Modern healthcare is distributed by nature • Clinical information systems are often

implemented in an ad-hoc manner. – These limitations have led to the fragmentation of

health information

Observations

• To ensure healthcare quality, we need actionable data

• We have enough data, but not when and where we need it

• Data must be available where needed, when needed

• We need standardized data exchange

Ontology

The specific words that need to be used in the letter

Content structure

The structure and specific type of information in the letter or package –how to write a business letter

Transport

The method used to move the letter or package (e.g., truck, plane, boat) from point A to point B

Security

Sealing the envelope or the package

Services

Delivering to intended recipient and being able to find their address

Interoperability Building Blocks

Semantic Syntactic Technical

Slide thanks to Masoud Hosseini (PhD Candidate, SOIC)

Syntactic Interoperability and standardization

• Decades old domain• Numerous competing standards– HL7, DICOM etc.

• Different versions– HL7 V2 and V3, CDA, CCD

• Wide range of commercial tools / API’s– Mirth, HAPI, NHAPI, Everest

Have these accomplished their goals?

The HL7 Family

• Health Level Seven International (HL7)• Since 1987• A not-for-profit, ANSI-accredited standards

developing organization• (Aims to) provide a comprehensive framework and

related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation of health services.

HL7 V2

• Multiple message types– Patient Administration (ADT)– Orders (ORMs)– Results (ORUs)– Charges (DFTs): Money, of Course!

http://healthstandards.com/blog/2006/10/05/what-are-the-hl7-message-types/

Each message type contains many messages

• ADT-A01 – patient admit• ADT-A02 – patient transfer• ADT-A03 – patient discharge• ADT-A04 – patient registration• ADT-A05 – patient pre-admission• ADT-A08 – patient information update• ADT-A11 – cancel patient admit• ADT-A12 – cancel patient transfer• ADT-A13 – cancel patient discharge

Each message composed of multiple segment

• MSH: Message Header• PID: Patient Identification• PV1: Patient Visit Information • OBR: Observation Request• OBX: Observation Segment

HL7 RIM

Slide thanks to Masoud Hosseini (PhD Candidate, SOIC)

HL7 V3

• A suite of specifications based on HL7’s Reference Information Model (RIM)

• Both messaging and document standards

http://ontology.buffalo.edu/HL7/doublestandards.pdf

Clinical Document Architecture (CDA)

• A document markup standard that specifies the structure and semantics of clinical documents.

• CDA conforms to the HL7 V3 Implementation Technology Specification (ITS)

• Is based on the HL7 Reference Information Model (RIM), and uses HL7 V3 data types.

A CDA document could be

• Discharge summary• Referral• Clinical summary• History/physical examination• Diagnostic report• Prescription etc.• Any document that might have a signature is a

viable document for CDA.

Levels of Interoperability

• Level 1: CDA Header plus a body consisting of an unstructured blob, such as PDF, DOC, or even a scanned image.

• Level 2: CDA Header plus an XML body with narrative blocks. Each section identified with a code.

• Level 3: CDA Header plus an XML body with narrative blocks and entries. The section should be encoded with the full power of the RIM with vocabulary such as LOINC, SNOMED, CPT, etc.

Continuity of Care Document (CCD)

• A constraint on the HL7 Clinical Document Architecture (CDA) standard

• Meaningful Use, Stage 1: CCD and Continuity of Care Record (CCR) were both selected as acceptable extract formats for clinical care summaries.

Consolidated CDA (C-CDA)

• Meaningful Use, Stage 2: CCD, but not the CCR, was included as part of the standard for clinical document exchange. The selected standard is known as the Consolidated Clinical Document Architecture (C-CDA)

• Developed by Health Level 7 and includes nine document types

Examples!

http://wiki.ihe.net/?title=Profiles

OpenMRS and the HL7 familyHL7 V2 Import Yes ADTA08 & ORUR01 in OpenMRS core,

RGRTA module(ORU,ADT), CHICA module (ADT, ORU,VXR,VXX)

HL7 V2 Export Yes HL7Query module, RGRTA module(ADT,ORU), CHICA module (ORU,VXQ, VXU)

CCD Export Yes Export CCD module (GSOC)CCD Import No RGCCD moduleCDA Export Yes… CDA Generator module (GSOC)CDA Import No

FHIR • Fast Health Interoperable Resources• The latest and the greatest• Combines the best features of HL7’s Version 2,

Version 3 and CDA• Published as a Draft Standard for Trial use• Will (eventually) become a full normative

specification (in 2016?)• Currently undergoing rapid adoption

FHIR resource types

https://www.hl7.org/fhir/resourcelist.html

FHIR Maturity Model (FMM)

• Based on the CMM (Capability Maturity Model) framework

• Seeks to inform a sense of how mature a resource is

• Informed by implementability!http://wiki.hl7.org/index.php?title=FHIR_Maturity_Model

FHIR Operations

https://www.hl7.org/fhir/operations.html

FHIR Documents

https://www.hl7.org/fhir/documents.html

FHIR Value Sets

• https://www.hl7.org/fhir/terminologies-valuesets.html

FHIR Profiles

• The (base) FHIR specification describes a set of (base) resources

• There is wide variability between jurisdictions and across the healthcare ecosystem around practices, requirements, regulations, education and what actions are feasible and/or beneficial.

• Therefore, FHIR specification usually requires further adaptation to particular contexts of use.

Adaptations can specify

• Rules about ;– Which resource elements are / are not used, and

what additional elements are added that are not part of the base specification

– Which API features are used, and how– Which terminologies and used in particular elements– Descriptions of how the resource elements and API

features map to local requirements and/or implementations

HL7 V2 Vs. CDA Vs. FHIR Contd. • Extensibility

– V2 offers Z segments whose meaning is opaque unless prior communication by sender. In comparison, the meaning of FHIR extensions are discoverable by resolving the URI that defines each extension

• Cleanliness– V2 messages are the most cluttered , CDA less cluttered, FHIR least

cluttered• Relationship to non-HL7 Standards– FHIR resources can provide direct implementation of functionality from

other standards such as DICOM• JSON

– FHIR supports JSON

HL7 V2 Vs. CDA Vs. FHIR

• Practical applications– CDA is restricted to clinical settings. V2 and FHIR can be used in other

contexts as well. • Reusability

– V2, CDA and FHIR are all built around the idea of re-usable segments, but only FHIR segments maintain truly independent identities

• Human readability– V2 offers NTE segments, FHIR and CDA require human readable

content for all resources• Messaging paradigms

– V2 supports event based messaging. CDA does documents. FHIR does both, plus REST and service models

Why FHIR stands out…

• Is for developers• supports JSON• Modular by design• In DSTU, and willing to listen to our needs• Plenty of interest• Adoption by major players– Project Argonaut

Demo!

Resources

• FHIR Documentation : http://hl7-fhir.github.io/• Mailing lists : fhir@lists.hl7.org / • Hapi Demo server: http://fhirtest.uhn.ca/• FHIR Reference implementation :

http://www.hl7.org/documentcenter/public/standards/FHIR/fhir-0.0.81-Java-0.81.zip

Contacts : surangak@openmrs.org

Questions

Thank You!