getting smart with fhir - hisa

Australia’s National Science Agency

Getting SMART with FHIR

Grahame Grieve, Mark Braunstein, Michael Lawley, Brett Esler, Reuben Daniels, Kate Ebrill, Steve Badham, Andrew Patterson, Danielle Bancroft, Brian PostlethwaiteAugust 2019

1. FHIR rapidly spreading around the World- Grahame Grieve2. Fueling FHIR for change in the US- Mark Braunstein3. Quick FHIR: initiatives across Australia

o HL7 Au - Brett Esler

o SafeScript - Danielle Bancroft

o Federated Provider Directory - Brian Postlethwaite

o National Children’s Digital Health Collaborative - Steve Badham

o Queensland Clinical Terminology Service - Reuben Daniels

o Genomics Alliance’s supported by FHIR - Andrew Patterson

o Primary Care Data Quality and Practice to Practice Exchange - Kate Ebrill

Agenda

Mentimeter- getting to know who is in the room

FHIR: Spreading around the world

Grahame Grieve

13-Aug 2019

Melbourne (IHE/HIC)

FHIR: The web, for Healthcare

Open Community Open Standard

• Make it easier to exchange healthcare information

• Open Participation - uses web infrastructure (social media)

• Lead by HL7 - deeply connected to world wide health community

• Describes how to exchange healthcare information

• A web API - web standards where possible

• Continuity with existing healthcare standards

• Public Treasure (http://hl7.org/fhir)

http://hl7.org/fhir

FHIR History

Standards History

• July 2011 - Conception

• May 2012 - First Milestone

• Sept 2014 - R1 (Trial Use)

• Oct 2015 - R2

• April 2017 - R3 (CC0)

• Dec 2018 - R4 (1st Normative)

• Oct 2020? - R5

Implementation History

• Sept 2012: 1st Connectathon

• June 2014: Commonwell (1st Prod)

• Sept 2014: Reorientate

• Dec 2014: Argonaut

• May 2016: FHIR Foundation

• Jan 2018: Apple Healthkit

• Late 2019?: R4 required in US Regs

Three Legs of the Standards Process

• Base Standard• Establish Capabilities• Common Engineering• V2, FHIR, DICOM, LOINC, SNOMED, XDS?

• Profiling for Communities• Common Use Cases, Smaller communities (Wishel Rule)• Adapt / Combine • IHE, Argonaut / Da Vinci, ADHA / IT-14

• Driving Solutions into the Market• Regulation, Incentive Payments – ONC, ADHA, etc• Trade Associations - HIMSS / HISA,

Overall Progress

Where adoption is happening

• Secondary Data Repositories• Patient access to data• Big Data • Specific Clinical Data Repositories • National Health Records / Sharing frameworks

• Application Extension• Argonaut / EHR Plug-ins• Decision Support Integration

• Primary Apps: SaaS (health)

• Interaction between Payers and Providers (pre-auth, approval, review processes)

Adoption: USA / Argonaut

• Clinical Summary Query (R2 -> R4)

• Provider Directory

• Scheduling

• Clinical Notes

• Questionnaire

• Active Health Nodes – provide services to enable a distributed healthcare system

• Clinical Summary (R4) required in next regulations

Adoption: USA / Da Vinci

• Prior Authorization

• Coverage Decision

• Payer Data Acquisition

• Care Plan / Medicine Formulary Exchange

• Clinical Data/Documentation/Record Exchange

• Alerts

Adoption: USA / Federal

• Blue Button (2) – Government + Payer reporting of payment information)

• Quality Measure (Data Collection / Reporting)

• National Provider Directory

• NIH Endorsement

• Public Health / Death reporting

• VA Clinical care projects

Adoption: US Vendors

• Many personal health projects • Apple Healthkit – expanding scope & range

• Many Data Analytics / Repository Projects• Google Brain Project

• Many Toolkits / Frameworks • SmileCDR (HAPI!)

• Microsoft Azure FHIR Server

Adoption: Europe

• International Patient Summary

• “Document” – clinical summary for a patient

• Corresponds roughly to Argonaut scope

• Packaged as a document, not an API (push)

• Makes rules about terminology (SNOMED CT)

• Not just Europe

• MedMij - Personal health data in the palm of your hand

• Mobile access to all medical data over life time

• MedMij covers legal, organizational, financial, semantic and technical aspects

• 4 year initial project – 2016 - 2020

Adoption: Netherlands

Adoption: England / UK

• Interopen Project

• Renal Clinical Repository

• Many vendor projects

Adoption: Australia

• National Clinical Terminology Service (on Ontoserver)

• Provider Directory Project (supporting secure messaging)

• Document access to MyHR for mobile apps

• Agency strongly interested in FHIR documents going forward

• Lots of internal use in vendors (Telstra Health, Alcidion)

• Some classic interop in GP space• Appointments / decision support

• Not in common use in institutions yet

Common Production Uses for FHIR

• Exchanging Clinical Summary / Clinical Transfer

• EHR Extensibility

• Patient / provider registration

• Data Analytics / Surveillance

• Quality Measures / Clinical Performance

Join Us

• FHIR is a critical infrastructure enabler • A community solution for the IT requirements

• But FHIR is not a solution to anything itself

• Need new community infrastructure at many levels• Governance is critical: Build confidence and trust – open community treasure

• Needs stable Governance foundations with consistent transparency

• Join the community (FHIR, or others) • http://hl7.org/fhir, http://fhir.org

http://hl7.org/fhir

http://fhir.org/

Fueling FHIR for Change in the US

Mark L Braunstein, MDVisiting Scientist

Australian eHealth Research Centre

Professor of the PracticeSchool of Interactive ComputingGeorgia Institute of Technology

2016: 21st Century Cures Act

Interoperability

Data blocking

Patient access (APIs)

2009: American Recovery and Reinvestment Act

EHR Adoption and Meaningful Use

US Federal Interoperability Mandate

2019: Promoting Interoperability (PI) program2014: Argonaut Project

Using FHIR!

“By identifying the FHIR standard to implement our policies, we are promoting scalable data sharing, not just an individual patient record from hospital to hospital but a model that supports the flow of information across the entire healthcare system.”

--CMS Administrator, Seema Verma, HIMSS 2019

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Industry is Aboard

Amazon, Google, IBM, Microsoft, Oracle, and SalesforceCMS Blue Button 2.0 Developer Conference, July 30, 1019

“…we are fortunate to work with many teams and partners that draw on experiences across industries to support and accelerate the delivery of FHIR APIs in healthcare. Moreover, we are committed to introducing tools for the healthcare developer community. After the proposed rule takes effect, we commit to offering technical guidance based on our work including solution architecture diagrams, system narratives, and reference implementations to accelerate deployments for all industry stakeholders. We will work diligently to ensure these blueprints provide a clear and robust path to achieving the spirit of an API-first strategy for healthcare interoperability.”

http://blog.hl7.org/cloud-providers-unite-for-healthcare-interoperability-fhir

App Ecosystems for Providers

… and for Patients

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FHIR Gateway

SMART Apps

What Problems?

https://med.stanford.edu/content/dam/sm/ehr/documents/EHR-Poll-Presentation.pdf

EHRs: Mixed Results

CC/HPI: Abdominal Aortic Aneurysm Case

Problem Specific Structured Documentation

Key Findings Highlighted

PE: Abdominal Aortic Aneurysm Case

Procedure Reports

Varicose Veins Assessment/Plan

Procedure Note

Questionnaires/Scoring

Quality ofLife Score

Notes Management

Timeline Display

Timeline Standalone

Write-back

FHIR DocumentsDiagnoses/Problems (ICD-10) via FHIR or Proprietary API

• Epic

• Cerner

• Allscripts

• Athena

• Nextgen

Vault: Hierarchical Condiiton Coding

Each HCC is mapped to an ICD-10 code. Along with demographic factors (such as age and gender), insurance companies use HCC coding to assign patients a risk adjustment factor (RAF) score.

PCPs Needs versus Capabilities

Continuous, Coordinated Care

EHR Data

Patient GeneratedData

Integrated patient messaging(provider coming)

Targeted Information

Trend Insights

Suggested Evidenced-based Goals

Predictive Analytics

Estimated A1C on currentversus proposed therapy

Personalized Clinical Decision Support

Automatic Attribution

Medicare

Reduce patient burden

A research organization can pre-populate a medication lists for a patient during clinical trial

enrollment.

Streamline information about different kinds of care over time

A primary care physician can access information on other patient care (e.g. related to behavioral

health) to better inform treatment.

Uncover new insights that can improve health outcomes

A pharmacy can determine if a beneficiary gets healthier over time due to medication

adherence.

Access and monitor health information in one place

A health application can aggregate data into a health dashboard for beneficiaries.

VA API

Da Vinci Project: Value-based Care

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“The goal is to enable improved patient care outcomes as well as empower better clinical decision making by shifting key information into provider teams’ work flow and sharing that information across organizational boundaries.”

https://www.pocp.com/biopharma-davinci-project

Mentimeter- reflecting on the presentations…

Australian initiatives implementing FHIR

Quick FHIR

Provider

DirectoryCSIRO

Primary Care

AU Base

FHIR Core

Child

Health

AU Standards

AU Argonaut

MedView

• Medication platform using a FHIR server with Cosmos DB

• Framework provides a third party integration platform

• MedsList and MedsRec key apps in ADHA testbed project – real-time discharge and admission between acute and primary care

• Integrated with MyHR for upload of Meds Reconciliation (Pharmacist Shared Medication List – PMSL)

RTPM (SafeScript and NDE)

• Use of medication order and medication dispense order resources for API pre-check

• Investigating EMR FHIR platforms for health service SSO

ePrescribing

• Investigating conformance requirements and currently prototyping workflows.

• Investigating potential use of Azure on FHIR

• HL7 Australia Profile

• Supporting Secure Messaging• ADHA SMD POC

• Federated Deployment

• Service Registration Assistant

• NHSD

• VhDir International Guide

• FHIR STU3 vs R4

FHIR Provider Directories NHSDADHA SRA

Best PracticeTelstra Health

Secure Messaging

HealthLink Secure

Messaging

Global Health

Secure Messaging

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Paper Records Harmonised ContentClinical Information

Specifications & ModelFHIR Implementation Guide

Consumer Held Child Health Record

• Sharing of child health information between consumers and multiple providers

• Jurisdictional Child Health Record (baby book) Custodian

• Full clinical and consumer consultation by each jurisdiction

Harmonised Clinical & Consumer Content

• Nationally agreed core components of a child health record

• Ensure each jurisdiction’s data is represented in the national data set

• CDHR Harmonisation Expert Committee (Jurisdictional Child Health Record Custodians)

• Australian Health Ministers Advisory Council (AHMAC) – Health Services Principal Committee (HSPC)

• Targeted Consultation by jurisdictional Child Health Record custodians

Clinical Information Specifications & Model

• Spec: How the information will be structured in a digital record

• Model: The clinical information presented for clinical review and endorsement

Spec:• Internal Review• Terminology Review by CSIRO

Model:• Clinical Informatics Endorsement

Committee (Peak Bodies & Colleges eg RACGP, RACP, etc)

Spec:• Clinical TIGER team – Clinical

questionsModel:• Endorsed through the organisation’s

standard endorsement process• Reviewed by National Research

Advisory Group to identify research gaps

Child Data Hub to CIS & Consumer App Information Exchange

• Industry agreed specification for the exchange of clinical information

• HL7 Child Health Working Group

• HL7 Australia (International Standard)

• FHIR Implementation Guide profiles based on the HL7 Australia base resources collaboratively developed through the working group

High (≥50% Use) Medium (30-49% Use) Low (<30% Use)

Child InformationNat %

UseW/S

OutcomeBaby's Name 63 CName of Birth Facility 100 ADate of Birth 100 CTime of Birth 75 ASex (Male) 75 CSex (Female) 75 C


UseW/S

OutcomeThis section is to be completed by a health professional

38 E

Baby's Given Name/s 38 CBaby's Family Name 38 CAddress 38 CBaby's Blood Group 38 E


UseW/S

OutcomeUR (Unique Reference) 13 E

Examiner Name 25 E

Maternal InformationNat %

UseW/S

OutcomeMother's Name 63 CPregnancy Complications 63 AMother's Blood Group 63 ELabour (Spontaneous) 63 ALabour (Induced) 63 ALabour (Induced - Reason) 63 AType of Birth (Normal/Vaginal) 75 AType of Birth (Breech) 75 AType of Birth (Forceps) 75 AType of Birth (Caesarean) 75 AType of Birth (Vac Ext) 75 A


UseW/S

OutcomeAnti D Given 38 ELabour Complications 38 EType of Bi rth (Home) 38 EType of Bi rth (Other) 38 EType of Bi rth (Other, Specify Details) 38 EPostpartum issues 38 E


UseW/S

OutcomeMother's Given Name 25 CMother's Family Name 25 CFather's Name 13 CMother's Date of Birth 13 EMother's Home & Mobile Phone 25 EMRN (medical record number) 25 CType of Bi rth (write) 25 EType of Bi rth (water) 25 EDelayed cord clamp 13 TBirth Complications 25 EMaternal GBS Status 13 EMaternal GBS Status - Antibiotics given? 13 EMaternal rubella TITRE 13 EMother has had in pregnancy (CMV / Toxoplasmosis / Rubella

13 E

Workshop IdentifiedNat %

UseW/S

OutcomeFathers Given & Family Names ASex Other TOther Parent A

LegendA Agreed (Include) AA Agreed for ATSIT To be Agreed C Core DataO Out of Scope E Exclude

CDHR Clinical & Consumer Information Management

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Data Source Conceptual Data Item Logical Data Item Logical Data Item Description Logical Data Item

Code (If

Applicable)

Field Type ValueSet

Elements

ValueSet

Element Code

ValueSet Description Field Type Format Priority Cardinality

Harmonised (H)

Content impacts

from orchestartion

(O) (operational)

(OP)/ (F) FHIR /

restrictions /

enhancements ( E )

BOLD equals

Harmonised data

Name of the Data Item The description of the logical data

item description

SNOMED Code

which represents

the data item

FHIR

Date, text, checkbox,

radio button,

numeric, drop down

list

Name of ValueSet

Element Item

BOLD equals

Harmonised data

SNOMED

Code which

represents the

data item

The description of

the element

Date, text,

checkbox,

radio

button,

numeric,

ValueSet

eg

DD:MM:YYY

Y

Mandatory/

Required/

Optional

Relationshi

p of x to y

eg IHI is 1..1

First Name (Given)

First Name - will represent the

name of baby ie 'Baby of <mother

first name>'

FHIR Text Text String Required 0..1

Last Name (Family)Last Name - will represent the last

name of motherFHIR Text Text String Required 0..1

First Name (Given) First name of Mother FHIR Text Text String Required 0..*

Last Name (Family) Last name of mother FHIR Text Text String Required 0..1

OR

Full Name

Full Name of Mother (used where

First and Last names are not split

into separate fields in a system)

FHIR Text Text String Optional 0..1

*Street Address Street name, number, PO box etc FHIR Text Text String Optional 0..*

City Name of City, Town FHIR Text Text String Optional 0..1

State State in which the baby lives FHIR Text Text String Optional 0..1

Postal Code Postal code for area FHIR Text Text String Optional 0..1

Country Name of Country FHIR Text Text String Optional 0..1

First Name (Given) First name of Father FHIR Text Text String Optional 0..*

Last Name (Family) Last name of Father FHIR Text Text String Optional 0..1

OR

Full Name

Full Name of Father (used where

First and Last names are not split

into separate fields in a system)

FHIR Text Text String Optional 0..1

H Address

H Father's Name

Newborn Delivery Health Interaction (DEFINITIONS) - LOGICAL MODELNOTES / VERSION NO: 19/10 - 0.6

H Baby's Name

H Mother's Name

Queensland Clinical Terminology Service (QCTS)

VisionTo provide a lasting and effective solution for the management and meaningful use of up-to-date coding system reference data as well as associated artefacts (such as value sets and concept maps) which meets Queensland Health’s business and clinical needs.

Use of HL7 Fast Healthcare Interoperability Resources (FHIR)• Introduction of

– ValueSet, ConceptMap, and CodeSystem FHIR resources to represent local terminology subsets, maps, and coding systems respectively.

– Terminology server applications exposing the HL7 FHIR Terminology Service API for application integration

• Adoption of:– FHIR R4

– The Australian Digital Health Agency’s National Clinical Terminology Service (NCTS) FHIR specifications for content types and Conformant Server Applications

– The AEHRC Ontoserver syndicating terminology server

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Queensland Clinical Terminology Service (QCTS)

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Solution Overview

The Clinical Genomics Order Cycle

Clinical system(EHR)

Lab order(LIMS)

BioinformaticsVariant

Interpretation

Lab report

start

WhoCSIRO AEHRCHL7, LOINC, SNOMEDGA4GH

What


Lab order(LIMS)


Interpretation

Lab report

• LOTS and LOTS of code systems in the genomic space – bringing them into official FHIR code systems and implementing into Ontoserver etc


Lab order(LIMS)


Interpretation

Lab report

WhoCSIRO AEHRCQGHAGenomics England

What

• Smart on FHIR clinical tools hooked into EHRs

• Genomics England has an ordering system that uses FHIR data models internally

• Phenopackets work to ensure pedigree etc can align against a FHIR data model


Lab order(LIMS)


Interpretation

Lab report

WhoMelbourne Genomics

What• GenoVic uses FHIR as its API at

the boundaries – and for internal data models

• consent codes and representation to standardise encoding of genomic consent forms (very much WIP)

WhoHL7 FHIR WG (international)

What


Lab order(LIMS)


Interpretation

Lab report

• aligning representation of variants to match thinking in GA4GH

• existing standards are the kings here (VCF, BAM) despite certain limitations

WhoHL7 FHIR WG (international)

What


Lab order(LIMS)


Interpretation

Lab report

• DiagnosticReport profiles to report back genomic results in standardised discrete units –across various genomic domain (cancer v rare disease etc)

• In Australia – currently more likely PDF

Existing Specifications Harmonised ContentPrimary Care Data

Dictionary FHIR Implementation Guide

Primary Care, Standards Data Specifications, Data Sets, KPIs, Assessments, FHIR, OpenEHR

Identification of all the existing specifications in Primary Care that would inform the development of the core data requirements.

Initial meeting of stakeholders to identify all potential data inputs, use cases and priorities for the projects.

Community established with clinical and technical working groups.Use case agreed- reusable core data set, associated SNOMED CT Value Sets and a FHIR IG to exchange.

Harmonised clinical data items and identification of core common items

Candidate core data elements which are common to multiple existing specifications, that enable structured data recording and data reuse.

Clinical Content and Technical Working Groups consensus on the core data items to be defined and included in a data dictionary and identification of the first use cases to exchange these core data items.

Outputs progressively developed and iterated through a series of face to face workshops (4) and webconferences (5)

Primary Care clinical information model

Release 1 of the Data Dictionary defines the core common data elements to enable quality use of information as well as enable the safe and meaningful exchange of information to other care providers. The Dictionary includes: meta data, definitions and recommended terminology bindings

Enter once, multiple use and interoperable exchange and reuse

Community, consensus based development process with multidisciplinary clinical content and technical working group.

Endorsement proposed to be progressed through clinical colleges and professional groups.

FHIR IG- Primary Care Au Practice to Practice Record Exchange

An industry agreed specification, informed by the Primary Care Data Dictionary Core Common Model for the exchange of an individuals record when they request a transfer of their records from their current practice to a

new practice.

FHIR IG profiles based on the HL7au Base resources, progressively developed and tested through a Community process.

Endorsement proposed to be progressed through HL7au

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Primary Care Data Quality P2P

Australia’s National Science Agency

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