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Laura Heermann PhD, RN, FAMIAIntermountain Healthcare
Clinicians on Wednesday June 9, 2021
Russ Leftwich MD, FAMIAIntersystems
Jim McClay MD, FAMIAUNMC For Meeting Materials https://tinyurl.com/June2021NKBDCoF
Nursing Knowledge: Big Data Science ConferencePreconference, Track 1
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FHIR®
JAMES MCCLAY, MD, MS, FACEP, FAMIAEMERGENCY MEDICINE, UNIVERSITY OF NEBRASKA MEDICAL CENTER
A Deep Dive into FHIR
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FHIR®FHIR | Agenda
• The basics: Resources and references• Structured and Coded Data• Terminology• Profiling• Ecosystem
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FHIR®The Goal:Share Computable Healthcare Knowledge Artifacts
• Computable knowledge artifacts are digital objects carrying healthcare information represented in data structures that can be parsed by a machine (Lehmann 2018).
• The FHIR resources represent self contained computable healthcare knowledge artifacts.
• The FHIR Resource Objects represent named healthcare related concepts based on common EHR based concepts.
• The FHIR resources are designed to be findable, useable, extensible specifications based on standard internet protocols.
Lehmann HP, Downs SM. Desiderata for sharable computable biomedical knowledge for learning health systems. Learn Health Syst. 2018;2(4):e10065. https://onlinelibrary.wiley.com/doi/full/10.1002/ lrh2.10065.
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FHIR®Modeling Health Information: Example Knowledge Artifacts
Clinical DataMedicationsDiagnosticsProblems and ConditionsProcedures and ResultsAllergiesFamily HistoryLabs, Radiology & Genomics…
Administrative DataPatient DemographicsProvider QualificationsEncounter DescriptionClaimsInsuranceOrganizational DescriptionsAppointmentsOrders management…Process Information
Care PlanningWorkflow SupportCare Episodes…
BasicsListsCompositionsBundlesLibrary
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FHIR®
BASICS OF FHIR
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FHIR®Overview of FHIR
• Fast Healthcare Interoperability Resources (FHIR)• Consistent, simple to use content model (Resources)
• Controlled extensibility• Supports all paradigms of exchange
• Real-time APIs• Documents, Messages & Services
• Designed with implementers in mind• Detailed on-line, hyperlinked specification• Freely available tooling, servers, libraries• Written into latest HHS regulations
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FHIR®Informed by and Related to other Healthcare Standards
• Health Level 7 (HL7)• Version 2• Version 3• CDA
• IHE• DICOM• Terminologies
• SNOMED• ICD• LOINC
Incorporates lessons learned from prior efforts
Iteratively designed by stakeholders and tested at regular connectathons.
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FHIR®The FHIR Specification
http://hl7.org/fhir/
Free: licensed under Creative Commons ”derivative works allowed“
Fully Documented
Currently in 4th Release
Release 5 anticipated mid-2022
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FHIR®Resources: What are they?
• The Content model (capital R)• Small logically discrete units of exchange• Defined behaviour and meaning = FHIR
specification• Known identity / location (URL)• Smallest unit of transaction• “of interest” to healthcare
• The Thing that is exchanged (small r)• Via REST ( FHIR Restful API), Messages, Documents
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FHIR®Resources: The FHIR Specification
http://hl7.org/fhir/resourcelist.htmlFive Level Maturity Model Applied to Each Resource:
http://wiki.hl7.org/index.php?title=FHIR_Maturity_Model
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FHIR®FHIR: the basics | Resource example: Patient
www.HL7.org/FHIR/patient
NAVIGATION HINT:
HL7.org/FHIR/NameOfResource
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FHIR®Resource structure
Resource Elements:• Name• Cardinality• Type• Description• Terminology binding• Other
Patient
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FHIR®FHIR the basics | References between resources
PROCEDURE
PATIENT
DIAGNOSTIC REPORTCONDITION
Subject
ReportRelated
Item
EncounterPerformer
ENCOUNTER PRACTITIONER
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FHIR®FHIR the basics |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 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 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
PatientAsserter
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 38°C
Inflamed right drum
Urticarial Rash
Amoxicillin 250mg
Erythromycin 250mg
Penicillin Allergy
As linked resources…
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Page 17 • HL7 New Zealand
Organizing Resources: Lists of things
• Examples– Medication list– Problem List (Conditions)– Allergies– Past Medical History– Past Social History– Social History– ‘Organizer’ in Document
• Manage ‘points in time’ and changes
List
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STRUCTURED AND CODED DATA
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FHIR®Why have structured / coded data?
• Structured vs Coded• Structured:
• Organized according to a schema, e.g. relational database• Ex: a collection of recipes stored as ingredients, mixing instructions,
cooking instructions, serving instructions• Coded:
• Improves UI possibilities• Improves exchange• ‘Secondary’ uses
• Allows Decision Support• Population health
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FHIR®Datatypes: Let’s look
• Review datatypes in spec• Start from resource
• Datatypes in resource definition• Backbone element• ‘choice’ data types
• Identifiers• Review coded data
• ValueSet binding
https://www.hl7.org/fhir/datatypes.html
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Vocabulary
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n Support for coded data of varying complexityn Some codes defined as part of resource, others referenced
from external vocabulariesØ LOINC, SNOMED, UCUM, etc.
n Recognition some will differ by implementation spacen Can use Value Set resource to define more complex code
lists
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FHIR®Terminology Sub-system
Code System:Defines a set of concepts with a
coherent meaning
CodeDisplay
Definition
Element Definition: Type and Value set reference
Value Set:A selection of a set of codes for
use in a particular context
Selects Binds
Element: code/
Coding/CodeableConcept
Refers to
Conforms
• SNOMED CT / LOINC / RxNORM• ICPC, MIMS + 100s more• ICD-X+• A drug formulary• Custom
https://www.hl7.org/fhir/terminologies.html
https://www.hl7.org/fhir/terminology-service.html
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FHIR®ValueSet
n A subset of terms from a code system for a specific purpose or use case
n Promotes consistency between applications
n Key component of TerminologyØ Also CodeSystem
n Skin TonesØ PinkØ RuddishØ WhiteØ GrayØ Yellow
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PROFILING
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FHIR®Adapting FHIR to your needs: Profiling
• Many different contexts in healthcare, but want a single set of Resources for 1 context• 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.
• 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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FHIR®For example…
Note: Limited mandatory elements in the core spec
Require that the identifier uses the NHS number – and is required
Limit names to just 1 (instead of 0..*)
Change maritalStatus to another set of codes that extends the one from HL7 international
Add an extension to support ethnicity
Doesn’t support photo
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Profiles
n Document constraints and extensions on one or more resources
n May also define new extensions search terms, new messaging events, etc.
n Subsumes: template, implementation profile, DCM (Detailed Clinical Model), etc.
n Looks an awful lot like the definition of the resources themselvesØ You can download profile XML for all resources
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FHIR®The ‘profile’
• Defines each element • Path • Name • dataType• Binding • Multiplicity • Mapping & much more
• Including allowable extension points
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FHIR®Extension Definitions
• Simple or Complex• Definition:
• Available on the web• Canonical Url
• Resolvable or Registry• In resource instance:
• Reference to Url• Extension or ModifierExtension
• Example: US Core – Patient Resource – Extended to include race and ethnicity.
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FHIR®Documents – are bundles
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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 ECOSYSTEM
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FHIR Implementation Guides
• FHIR Implementation Guides support Specific Use Cases• Implementation Guides both restrict and extend APIs, resources and
terminologies.• The Product of FHIR Accelerators• There are currently 152 FHIR Implementation Guides registered with
HL7
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FHIR®REST (API)
• “Representational State Transfer” –architecture for how to connect systems in real time• Uses HTTP/S• Simple to use• Very commonly used outside of healthcare – especially mobile• For simple interactions
• Create• Read (& Query)• Update • Delete
• A lot of tooling / experience available
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FHIR®Components
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Freely available
n Unencumbered – free for use, no membership requiredn http://hl7.org/fhir
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FHIR®
o From HL7 o HL7 FHIR:
http://hl7.org/fhir/index.htmlo FHIR Confluence:
https://confluence.hl7.org/o HL7 FHIR Foundation:
http://www.fhir.org/o Community
o https://chat.fhir.org/o List server ([email protected] )o Stack Overflow (tag FHIR)
o Blogso www.healthintersections.com.au/o https://fhirblog.com/o https://thefhirplace.com/o https://brianpos.com
More information
http://www.hl7.org/about/fhir-accelerator/
HL7 FHIR ACCELERATOR™ Projects
FHIR Implementation Guide Registry: https://www.fhir.org/guides/registry/
SMART on FHIR App Registry: https://apps.smarthealthit.org/