3. Page 3
About me
• Medical Doctor
• Developer
– EMR
– Tooling: clinFHIR, conMan
• HL7 Fellow
• Chair Emeritus of HL7 New Zealand
• Co-chair FHIR Management Group
• Contractor – MOH, Rhapsody, CSIRO, HL7 Intl.
• Blog: fhirblog.com
3
4. Page 4
Objectives for day
• Understand the basics of FHIR
• Feel confident to participate in a FHIR Implementation
• Know how to use clinFHIR / conMan tooling
• Know where to find more info and help
• Build the local community!
– Encourage people to comment on work…
7. Page 7
Technical Overview
• What is FHIR
• Resources
• Resource Graphs (incl. clinFHIR)
• Terminology
– Interaction and resources
• Exchange Paradigms
– CRUD operations
– Update operations
• PUT, PATCH, Operation
• Wire representation
– Extensions & Contained
• Implementer Support
– Tooling and Libraries
8. Page 8
What is FHIR
• Fast Healthcare Interoperability Resources
• An HL7 Interoperability Standard
– For sharing clinical information
– No assumption on storage form
– Focused on the now
• (with an eye to the future)
• 2 main parts
– Content Model (Resources)
– Exchange Specification
• Extending into
– Clinical Knowledge
– Decision Support
– Quality Measures
– Also being used for persistence
• Supported by a large community
– https://chat.fhir.org/
– Libraries
– Reference servers
® Health Level Seven and HL7 are registered trademarks of Health8
9. Page 9
Where can you use FHIR
9
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
FHIR
Application
PHR
FHIR
API Library
Database
FHIR
Integration Engine
V3
V2
10. Page 10
Timeline: Where does FHIR fit?
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
FHIR Maturity model & releases
1980 1990 2000 2010 2020
FHIR
CDA
V3
V2
V2
1987
Start V3
1995
V3 CDA
2005
Fresh Look
2011
FHIR Release 4
2018
11. Page 11
Where is it going?
• More resources
• Moving resources to Normative
– More implementation experience,
connectathons
• Moving beyond Interoperability
– Extending into Clinical Knowledge
• Decision Support
• Quality Measures
– Bulk extract and query
– Research
– Also being used for persistence
• Associated standards
– SMART
– CDS-Hooks
– Bulk Data
• Accelerating implementations
• Supporting the community
® Health Level Seven and HL7 are registered trademarks of Health11
12. Page 12
Who’s using it?
• Vendors
– Epic, Cerner, Allscripts
– Apple
– Microsoft
– Google
– Amazon
• Countries
– US - ONC
– UK
– Russia, Lithuania
– Australia, New Zealand
– Pretty much everywhere
12® Health Level Seven and HL7 are registered trademarks of Health
13. Page 13
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
13® Health Level Seven and HL7 are registered trademarks of Health
15. Page 15
References between resources
15
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
PROCEDURE
Patient
Diagnostic reportCondition
Subject
Report
Related
Item
Encounter Performer
Encounter Practitioner
http://hl7.org/fhir/references.html
16. Page 16
Recording a consultation
16
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
12-year-old-boy
First consultation
Complaining of pain in the right ear for 3 days with an
elevated temperature. On examination, temperature 38°C
and an inflamed right eardrum with no perforation.
Diagnosis Otitis Media, and prescribed Amoxicillin 250mg
3 times per day for 7 days.
Follow up consultation
2 days later returned with an itchy skin rash. No Breathing
Normal. On examination, urticarial rash on both arms. No
evidence meningitis. Diagnosis of penicillin allergy.
Antibiotics changed to Erythromycin 250mg 4 times per
day for 10 days.
Patient
Encounter
Condition
Observation
Medication
Allergy Intolerance
17. Page 17
First consultation as a Graph
17
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
18. Page 18
Visualizing the connections: conMan
18
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
20. Page 20
Resources: Type vs Instance
• ‘Type’ is the definition in the spec
– Like a template or a cookie cutter
• ‘Instance’ is a ‘filled out’ type
– Like a cookie
• Take Patient:
– Patient type (in spec) is what can be recorded for a patient
• (Can alter with Profiling)
– An actual patient is a particular instance of the Patient type
20® Health Level Seven and HL7 are registered trademarks of Health
21. Page 21
Contained resources
• Resources instances generally stand alone
– With references between them
• Contained resources:
– Resources ‘inside’ another
– When doesn’t have separate identity
• Wire format (‘contained’ element)
• Library support
http://hl7.org/fhir/references.html#contained
22. Page 22
Resource instance example
Resource Identity &
Metadata
Human Readable
Summary
Extension with URL
to definition
Structured Data:
•MRN
•Name
•Gender
•Birth Date
•Provider
XML and JSON
<valueString value=“jedi”/>
23. Page 23
Structured / coded data
• Unstructured vs Structured vs Coded
• Value:
– Greatly improves quality of exchange
– ‘semantic’ interoperability
• Secondary uses
– Decision Support
– Analytics
– Population Health
– Reporting
23® Health Level Seven and HL7 are registered trademarks of Health
24. Page 24
Resource type structure and definition
24
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
Examine the spec…
25. Page 25
Resource type Hierarchy
Resource
• Id
• Meta
Domain Resource
• Text
• Contained
• Extensions
Specific type
Bundle
26. Page 26
Base Types
• DataTypes
– Each element in an instance is a single datatype
• Spec indicates allowed types
• Choice element
– 2 classes of datatype
• Primitive
• Complex
• Other types
– MetaData
– Element
– Resource / Domain Resource
– Logical Model
26® Health Level Seven and HL7 are registered trademarks of Health
27. Page 27
Data types: Primitive (R3)
27
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
Based on w3c schema and ISO data types
• Stick to the “80% rule” – only expose what most will use
– Simplified
instant
Value : xs : dataTime 0..1
time
Value : xs : Time 0..1
date
Value : xs:gYear [xs:gYearMonth | Time 0..1
dateTime
Value : xs:gYear [xs:gYearMonth | xs:date | Time 0..1
decimal
integer
Value : xs : int 0..1
Element
Extension : Extension 0..
boolean
value : xs:boolean 0..1
string
Value : xs :string 0..1
uri
Value : xs :anyURI 0..1
base64Binary
Value : xs : base64Binary 0..1
unsignedint positiveInt code id oid
Value : xs :
decimal 0..1
29. Page 29
DataType: Identifiers
• Business identifiers
– NHI, Driving License, CSC Card, Lab order number
– Most resources have them (name is ‘identifier’ as well)
• Identifier datatype
– Key child elements
• System
– The ‘namespace’ within which the value is unique (uri)
» NamingSystem resource to describe
• Value
– The actual value
• Not the same as the resource Id
32. Page 32
Why have structured / coded data
• Unstructured vs Structured vs Coded
• Value:
– Greatly improves quality of exchange
– ‘semantic’ interoperability
• Secondary uses
– Decision Support
– Analytics
– Population Health
– Reporting
32s of States
34. Page 34
Terminology Sub-system
34
Code System:
Defines a set of concepts
with a coherent meaning
Code
Display
Definition
‣ SNOMED CT / LOINC
‣ NZULM / NZMT
‣ ICPC, MIMS + 100s more
‣ ICD-X+
‣ A drug formulary
‣ Custom
35. Page 35
Terminology Sub-system
35
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
Code System:
Defines a set of concepts
with a coherent meaning
Code
Display
Definition
Value Set:
A selection of a set
of codes for use in a
particular context
Selects
36. Page 36
Terminology Sub-system
36
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
Code System:
Defines a set of concepts
with a coherent meaning
Code
Display
Definition
Value Set:
A selection of a set
of codes for use in a
particular context
Element Definition:
Type and Value set
reference
Selects Binds
▸ Binding:
Connection between element and ValueSet
Strength determines if can change
37. Page 37
Terminology Sub-system
37
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
Code System:
Defines a set of concepts
with a coherent meaning
Code
Display
Definition
Value Set:
A selection of a set
of codes for use in a
particular context
Element:
code/
Coding/
CodeableConcept
Element Definition:
Type and Value set
reference
Selects Binds
Refers to
Conforms
38. Page 38
Terminology Sub-system
38
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
Code System:
Defines a set of concepts
with a coherent meaning
Code
Display
Definition
Value Set:
A selection of a set
of codes for use in a
particular context
Element:
code/
Coding/
CodeableConcept
Element Definition:
Type and Value set
reference
Selects Binds
Refers to
Conforms
Definition
Instance
39. Page 39
Terminology binding: Condition resource
39
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
• a
ValueSet binding in the spec…
40. Page 40
Canonical Urls / system
• Certain resources
– http://hl7.org/fhir/references.html#canonical-list
• StructureDefinition
– Profile and Extension Definition
• ValueSet
• CodeSystem
– Element name is ‘url’
• Is really a URI
– Globally unique
• Eg Extension definition or profile url
– A form of reference
• Eg ValueSet to CodeSystem
• Should resolve (usually) but not required to
– Eg support registry
43. Page 43
Adapting FHIR to your needs: Profiling
• Many different contexts in healthcare, but want a single set
of Resources
• The 80% rule
• 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 registry & Discoverable
– Used as the basis for validation, code, report and UI generation.
• Profiling adapts FHIR for specific scenarios
– A Statement of Use
43® Health Level Seven and HL7 are registered trademarks of Health
44. Page 44
FHIR as a platform spec
• Base on which profiles / IGs are created
• ‘80%’ rule
• Minimum required fields
• Minimum ‘required’ bindings
Base Spec Profiling Customized Spec
Eg IPS
45. Page 45
More on Profiling
• 3 main aspects:
– Constraining a resource - remove element, change multiplicity fix
values
– Change coded element binding
– Adding a new element (an extension)
• Modifier Extensions
• Each profile has a unique (canonical) url
– Represent as StructureDefinition resource
• Package multiple profiles as Implementation Guide
– Along with other artifacts (ValueSets, ConceptMaps etc.)
45® Health Level Seven and HL7 are registered trademarks of Health
46. Page 46
Example: Profile on a Patient
Limit names to
just 1 (instead
of 0..*)
Change
maritalStatus to
another set of
codes that
extends the one
from HL7
international
Specify that the identifier
uses the NHI – and is
required
Don’t
support
photo
Add an
extension
to support
ethnicity
48. Page 48
Extensions
• Extensions are normal
– Can occur at many levels in resource instance
• Same capabilities as core
• ‘Levels’ and reuse
– Core, National, Regional, Local
• Extension Definition
– (StructureDefinition)
• Canonical Url in definition
• Resource instance includes that Url
– Therefore client can locate definition
• Registry of extension definitions
48
® Health Level Seven and HL7
51. Page 52
Implementation Guide (IG)
• All the artifacts for a particular business need
– Outcome of profiling
• For an implementer
• Can be balloted by HL7
• Examples
– US Core
– Argonaut
– IPS
– QI-Core
– CCDA on FHIR
– Da Vinci (multiple)
– Provider directory
52® Health Level Seven and HL7 are registered trademarks of Health
http://www.fhir.org/guides/regis
52. Page 53
IG: General considerations
• Must Support
• Tooling
– Forge (https://fhir.furore.com/forge/ )
– Simplifier Registry (https://registry.fhir.org/)
– clinFHIR / conMAN (clinfhir.com)
• Governance
53® Health Level Seven and HL7 are registered trademarks of Health
53. Page 54
Demonstration
54
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
http://hl7.org/fhir/uv/ips/2019Sep/
International Patient Summary
57. Page 59
clinFHIR Logical Modeler
• Graphical tool to build model using FHIR datatypes
• 2 model types:
– Pure information (eg Adverse Reactions)
• Collect and document data from clinicians
• Can review and publish as HISO information standard
– Resource based (eg NHI / HPI)
• To generate FHIR artifacts for Implementation Guide
– Eg profiles
– Can follow Information model
• Review and publish in conjunction with HL7 NZ
60. Page 62
Exchange Paradigms
62
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
REST Documents
Messages
Services
(Operations)
61. Page 63
Bundles
• Container resource
• Types of Bundle
– Searchset
– Transaction
– Document
– Message
– …
• Inherit from Resource
– No text or extensions
63® Health Level Seven and HL7 are registered trademarks of Health
Bundle Resource
Patient Resource
List Resource
Condition Resource
62. Page 64
Exchange paradigm: REST
• Preferred paradigm
– Can be async
• Searching
– Defined searches per resource
• Can add others
– Chaining
– Parameters (eg _include)
– Results in Bundle
• Operations
– For more complex interactions (still real-time)
– Defined and Custom
• Eg Terminology search, $validate
– Parameters resource
Server can support any subset
63. Page 65
When to use REST?
• Want low coupling between systems
– In theory, very little up-front negotiation required
• Small, light-weight exchanges
• Focus is CRUD operations
– Also for publish/subscribe
• Client-driven client-server orchestration
• Server endpoint has fixed location
• Well-suited for Mobile, PHR, Registries
65
64. Page 66
When to avoid REST?
• Complex or server-driven orchestration
– Order of operations matters (e.g. complex decision support)
• Unit of work != resource
– “Transaction” may be an option
• No natural “server” or no fixed network location
• Lack of trust in the client for contextual audit, etc.
66
65. Page 67
Locating a single resource…
http://server.org/FHIR/Patient/1
base path resource type
id
Not the same as a resource identifier
66. Page 69
Business identifiers
• Id is not the same as a business identifier
– Eg a Medical Records Number
– Eg Patient.identifier, Encounter.identifier
• Id is ‘structural’ – depends on server
• Identifier is a resource property.
– Same if a resource is moved
69
67. Page 70
Specify format
URL: GET [server]/fhir/Patient/1?_format=json
Response: HTTP/1.1 200 OK
Response headers: Content-Type: application/json+fhir;charset=utf-8
Content-Length: 787
URL: GET [server]/fhir/Patient/1 HTTP/1.1
Request header: accept: application/fhir+json
Response: HTTP/1.1 200 OK
Response headers: Content-Type: application/json+fhir;charset=utf-8
Content-Length: 787
68. Page 71
CRU(P)D: Mapping to verbs
create
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 [base]/[resourcetype] (?_format=mimeType)
read
The read interaction accesses the current contents of a resource. The interaction is performed by an HTTP GET operation as
shown:
GET [base]/[resourcetype]/{id} (?_format=mimeType)
update
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 [base]/[resourcetype]/{id} (?_format=mimeType)
patch
The patch interaction updates an exiting resource by supplying a document with the list of changes to apply. The document
can be Json, XML or FHIR Path. The interaction is performed by an HTTP PATCH operation as shown:
PATCH [base]/[resourcetype]/{id}
delete
The delete interaction removes an existing resource. The interaction is performed by an HTTP DELETE operation as shown
(note logical delete & versioning):
DELETE [base]/[resourcetype]/{id}
69. Page 72
Versioning
• FHIR defines an API for managing changes
– Optional
• Previous versions can be listed / returned
– At resource level
• Delete is a ‘marker’ in the history
– Can re-animate with a PUT to the same location
• Resource history
– GET [base]/[type]/[id]/_history
• Get a specific version
– GET [base]/[type]/[id]/_history/3
– Version not necessarily a number
71. Page 74
Standard parameters
• Each resource has a set of “standard” search operations, so not every element can be searched
– Search name not always same as element name
• Can define custom ones
– SearchParameter resource
72. Page 75
Executing queries
• POSTMan - https://www.getpostman.com/
• Server declares support in CapabilityStatement
– GET [host]/metadata
– http://hl7.org/fhir/http.html#capabilities
• Returns a Bundle
– Watch out for paging
• _count parameter
• Reference database really helpful
– I use hapi (http://fhirtest.uhn.ca/baseR4/)
• clinFHIR to create sample data
– Patient Viewer -> Select Patient ? Add new patient
– Much more at synthea - https://github.com/synthetichealth/synthea
• Examples
http://snapp.clinfhir.com:8081/baseDstu3/Patient?name=hay
75
73. Page 76
Combining parameters
• Can search by GET & POST
• Multiple parameters
– Specifying multiple parameters finds resources matching all params “AND”
http://snapp.clinfhir.com:8081/baseDstu3/Patient?name=hay&gender=male
– Parameters may list multiple values “OR”
http://snapp.clinfhir.com:8081/baseDstu3/Patient?name=smith,hay
75. Page 78
Chained searches
• Search based on referenced properties
– http://hl7.org/fhir/search.html#chaining
• eg
– Observations for a patient
• Observation has a search for “subject” (the id of the Patient, Group or Device)
• Patient has a search for “name” and “identifier”.
• ‘chained’ search:
– [host]/Observation?subject.name={x}
– [host]/Observation?subject.identifier={y}
• But note: this still only works on the predefined search parameters. You cannot
just use any property of the resource.
http://snapp.clinfhir.com:8081/baseDstu3/Observation?subject.name=hay
76. Page 79
Reverse Chaining
• Selecting resources based on the properties of resources that refer to them
– http://hl7.org/fhir/search.html#has
• Return patients that have an Observation with a code of 9279-1
79
http://snapp.clinfhir.com:8081/baseDstu3/Patient?_has:Observation:patient:code=92
Particularly useful when using Proven
Return a patient ‘search’ property on Observation
Observation code
Observations
that reference
the patient
77. Page 80
_Include related resources
• Include related resources in the response
• Based on search parameters
• Server declares in conformance
• Format
– [host]/{type}?_include={source type}:{search parameter}:{target type}
• Eg
– [host]/MedicationOrder?_include=MedicationOrder:patient&criteria...
http://snapp.clinfhir.com:8081/baseDstu3/Observation?_id=7294&_include=Observation:patient
http://snapp.clinfhir.com:8081/baseDstu3/Observation?code=http://loinc.org|8310-
5&_include=Observation:patient
78. Page 81
Conditionals
• Perform an operation if conditions met
– Based on search parameters
• Conditional Read
– ‘If-modified-since’ header
• Conditional Create
– HTTP header
– If-None-Exist: [search parameters]
• Conditional Update
– PUT [base]/[type]?[search parameters]
• Conditional Delete
– DELETE [base]/[type]/?[search parameters]
https://fhirblog.com/2019/03/25/importing-csv-data-into-a-fhir-server/
79. Page 82
Custom queries
• Use SearchParameter to define
– http://hl7.org/fhir/searchparameter.html
• Useful for searches on extensions
• Like custom operations, does raise the interoperability bar
80. Page 83
Compartment
• Syntactic sugar for queries
• Resources that share common property
– Eg patient
• Purpose:
– Access mechanism for finding a set of related resources quickly
– Provide a definitional basis for applying access control to resources quickly
• http://hl7.org/fhir/compartmentdefinition.html
• Eg
– http://snapp.clinfhir.com:8081/baseDstu3/Patient/7268/$everything
81. Page 84
$match
• Defined operation for EMPI searching
• Send partial Patient resource
– Elements to match filled in
• POST to “Patient” endpoint on server
– Server applies business rules then (potentially) runs query
• Response is bundle of matching patients with score
{
"resourceType":"Patient",
"name":[{"family":"Doe"}],
"birthDate":"1987-03-12",
"gender":"male”
}
82. Page 85
GraphQL
• Allows queries to specify ‘shape’ to return
– Generally REST returns whole resource
– Though note _elements and _summary modifier
• Can operate on single resource or at the ‘system’ level
• Mostly query
– Update not well defined
• http://hl7.org/fhir/graphql.html
http://test.fhir.org/r3/Patient/example/$graphql?
query={name(use:official){text,given,family}}
83. Page 86
Updating patterns
• Resource PUT
– Replace the entire resource
• Patch
– The patch document
• Operations
– User defined update operations
84. Page 87
Resource PUT
• Submit an updated resource
• Client is in control (mostly)
• Server
– Doesn’t have to support
– Can apply business logic / security to call
85. Page 88
Validating first…
• Knowing the resource is valid
– Actually, ‘conformant’ is the preferred term
– Must be conformant to the core spec, additionally other profiles
• Validation code from the community
• $validate operation
– Most reference servers support
• http://hl7.org/fhir/validation.html
88
86. Page 90
Operations example
• Operations hide complexity
– Some in spec, can defined custom
• OperationDefinition resource to define
• Parameters resource
– Enclose input data
– Return result
• Custom operations are a barrier to global interoperability
– Not consistent across implementations
https://fhirblog.com/2019/07/09/thoughts-about-updating-registries/
https://ontoserver.csiro.au/stu3-latest/ValueSet/$expand
?url=http://hl7.org/fhir/ValueSet/condition-code&filter=asthma
87. Page 91
Parameters resource
• Use Parameters resource to pass parameters
{ "resourceType":"Parameters",
"parameter":[
{"name":"nhi","valueIdentifier":
{"system":"https://standards.digital.health.nz/id/nhi",
"value":"XXX1234"}
},
{"name":"address","valueAddress":
{"use":"home","text":"23 Thule Street "}
}
]
}
89. Page 93
PATCH example
• Update part of a resource
• Patch document
– Specify changes to make
– JSON, XML, FHIRPath
• PATCH [base]/[type]/[id] {?_format=[mime-type]}
• (Careful with arrays)
http://hl7.org/fhir/http.html#patch
https://fhirblog.com/2019/08/13/updating-a-resource-using-patch/
[{ "op": "add", "path": "/gender", "value": "female" }]
90. Page 94
Transactions & Batches
• Same principle as Db transactions
– POST a Bundle to server root
• Transaction
– Succeed / Fail as a unit
• Batch
– Partial update
• http://hl7.org/fhir/http.html
92. Page 96
Document paradigm
• Summary at a point in time
• Part of record
• Very common
– Discharge Summary
– Referral letter
– Progress Note
• A collection of resources
• Equivalent to CDA
– CCDA on FHIR
96® Health Level Seven and HL7 are registered trademarks of Health
Patient
Practitioner
Observation
Resource
Device
List
Condition
Composition
• Subject
• Author
• Section:Obs
• Section:Probs
List
Condition
Bundle
Note: Most resources have a reference to Patient
https://chat.fhir.org/#narrow/stream/179273-CCDA-.2F.20FHIR.20mapping.20stream
93. Page 97
Composition resource
• Document header
– Document type
– References to Patient, Author, Custodian …
– Equivalent to:
• CDA header
• IHE XDS metadata
• Sections (headings)
– Contents are text and structured/coded data
• Rules for rendering
• Can be profiled (i.e. specific document types)
97® Health Level Seven and HL7 are registered trademarks of Health
94. Page 98
Messaging
• Similar to v2 and v3 messaging
• Also a collection of resources as a
Bundle resource
• Allows request/response behavior
with bundles for both request and
response
• Event-driven
• Needs agreement between parties
– Tight coupling
• E.g. Send lab order, get back result
• Can be asynchronous and/or
indirect
95. Page 99
Conversion between v2 & FHIR
• Often replaced by REST
– (REST wasn’t an option until recently)
– Eg instead of ADT message, POST Patient resource to Lab server
• Conversion ‘reasonably’ straightforward
– Quite a few nuances though
• HL7 working on mapping advice
• https://chat.fhir.org/#narrow/stream/179188-v2-to.20FHIR
97. Page 101
Current NZ projects
• Adverse Reactions
– Improve collection of Adverse Reaction data
– Information model ready for comment
• FHIR interface for NHI / HPI
– Draft models created for phase 1
• Practitioner, PractitionerRole, Organization, Location
– Plan to release test API asap
– phase 2 will add services and careteams
• Medication query API against NZULM
– Support new users (ULM is complicated)
– Support new functionality (future phase)
• Bulk download for local caches
• Decision support
• CDS-hooks for EHR integration
– Plan to release test API asap
99. Page 103
Development Process
1. Confirm requirements
2. Setup Test server & project app
– http://nz.clinfhir.com/
– Currently standard FHIR server (HAPI)
3. Use clinFHIR Logical Modeler to build information models
– Use conMan to build resource graphs where useful
– Examples
4. Review models
– HISO document based process at the moment
– https://chat.fhir.org/#narrow/stream/179178-new-zealand
5. Build FHIR artifacts from models & publish in IG
– Extension definitions automatically
– Profiles combination manual / automatic
– ValueSets & CodeSystems manual
– Searches, queries, other technical stuff
– FHIR IG publisher to generate IG
6. Technical review / ballot
– With HL7 NZ – details TBD.
2 stage review as
technical review is
specialized.
Separate business &
technical aspects
100. Page 104
FHIR Community Process (FCP)
• Proposed process for building FHIR Implementation Guides
– Minimize overlap between IGs
– Encourage/support community development
– HL7 membership encouraged – not required
• Co-ordination committee
– Clearing House, not veto
• Each project:
– Documented governance process for IG development
– Description, License, Maintenance Plan, Realm
• https://wiki.hl7.org/index.php?title=FHIR_Community_Process
101. Page 105
clinFHIR Logical Modeler (redux)
• Graphical tool to build model using FHIR datatypes
• 2 model types:
– Pure information (eg Adverse Reactions)
• Collect and document data from clinicians
• Can review and publish as HISO information standard
– Resource based (eg NHI / HPI)
• To generate FHIR artifacts for Implementation Guide
– Eg profiles
– Can follow Information model
• Review and publish in conjunction with HL7 NZ
110. Page 114
Security
• FHIR is not a security standard, but…
• Existing privacy well aligned with GDPR
– (https://healthcaresecprivacy.blogspot.co.uk/2015/04/privacy-
principles.html)
• Current FHIR support:
– AuditEvent, Provenance, Consent
– Any resource has security tags
– Authentication/Authorization
• SMART on FHIR, Pages in spec
– Identity resources
• Patient, RelatedPerson, Practitioner, Organization & others…
• Some gaps and areas for improvement
– White paper to come
114® Health Level Seven and HL7 are registered trademarks of Health
111. Page 115
Blockchain
• Technology behind bitcoin
• Distributed list of transactions (blocks)
• Cryptographically signed
– Can’t change without detection
• What is relationship with FHIR?
– Unlikely actual clinical data
– Tamper proof audit records
– Provider Authentication
– Supply chain (eg medication provenance)
115® Health Level Seven and HL7 are registered trademarks of Health
112. Page 116
SMART
• Substitutable Medical Applications, Reusable Technologies
– http://hl7.org/fhir/smart-app-launch/
• History
• Originally limited to EHR external apps
– Becoming the ‘de-facto’ Authentication
• 2 aspects
– App launching
• Public & confidential
– Authentication ‘Profile’ on OAuth2 & OpenID Connect
• Endpoints and scopes
• Sandbox: https://sandbox.smarthealthit.org/#/start
• App Gallery: https://apps.smarthealthit.org/
116® Health Level Seven and HL7 are registered trademarks of Health
113. Page 117
Oauth2
App Resource
Server
Authz
Server
1. Delegate
Authorization
3. Use App
4. Authenticate and Grant access
5. Issue code
7. Access resource
(with token)
2. Application is
registered with Auth
server
6. Request access
token (+refresh token)
Repeat step 6 when access token expires
114. Page 118
Ecosystem
• An ecosystem really needs one, shared Auth server
– Most implementations combine Auth & Data servers
• For this to work, more standards will help
– Dynamic Client Registration (RFC 7591)
– Token introspection (RFC 7662)
– Server discovery (RFC 5785)
• More granular scopes
• Common Consent models
• Standardized auditing
– So consumer can see who accessed their data
More data: bit.ly/smart-fhir-tech
115. Page 119
CDS Hooks
• Clinical Decision Support (CDS)
– User Interface for display CDS
– ‘hooks’ to EHR activity
• Service can call back to EHR
– Or any other data store
• Discovery & endpoints
• Prefetch
• Security Model
– ‘out of band’ setup
• Key exchange
– TLS
– Encrypted JWT in call to service
– Access token provided for call back
119® Health Level Seven and HL7 are registered trademarks of Health
http://cds-hooks.org/specification/1.0/
https://chat.fhir.org/#narrow/stream/179159-cds-hooks
116. Page 120
Bulk Data
• Population level data
– Multiple patients
– Large data sets
• Define operations
– $export / $import
– ndjson as format
• Asynchronous operation
• SMART as security
• Still in development
• http://hl7.org/fhir/uv/bulkdata/STU1/
• https://chat.fhir.org/#narrow/stream/179250-bulk-data
117. Page 121
Decision Support
• Clinical Reasoning module
• 2 main use cases
– Sharing knowledge artifacts
– Evaluating knowledge artifacts in the context of a population
• Decision Support, Quality measures
• A complex area!
• http://hl7.org/fhir/clinicalreasoning-module.html
• https://chat.fhir.org/#narrow/stream/179220-cql
119. Page 123
Reality check
• Sounds wonderful!
• Managing Expectations
• Analogy of building house
– All this is the concept plan…
• What does FHIR really stand
for?
Far Harder In Real life!
® Health Level Seven and HL7 are registered trademarks of Health123
120. Page 124
More information
• From HL7
– http://hl7.org/fhir/index.html
– wiki.hl7.org/index.php?title=FHIR
• Community
– http://www.fhir.org/
– https://chat.fhir.org/
– List server (fhir@lists.hl7.org )
– Stack Overflow (tag FHIR)
• Blogs
– www.healthintersections.com.au/
– https://fhirblog.com/
– https://thefhirplace.com/
– https://brianpos.com
• Libraries
– Java (http://hapifhir.io/)
– C# (NuGet HL7.FHIR)Tooling
– Forge (http://fhir.furore.com/Forge)
• Tooling
– Forge (http://fhir.furore.com/Forge)
– http://clinfhir.com/
• Test servers
– http://wiki.hl7.org/index.php?title=Publicly
_Available_FHIR_Servers_for_testing
– https://fhirblog.com/2016/10/19/setting-
up-your-own-fhir-server-for-profiling/
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
124
121. Page 125
That’s it!
® Health Level Seven and HL7 are registered trademarks of Health Level Seven International, registered with the United States Patent and Trademark Office.
1