fhir –the api for healthcare - apidays australiaau.apidays.io/slides/hay-fhir.pdf · fhir is the...

FHIR – THE API FOR HEALTHCAREDAVID HAY | OCTOBER 2016

• 2016 © Orion Health™ group of companies

Dr. David Hay

▸ Medical Doctor▸ Chair emeritus of HL7 New Zealand▸ Co-chair FHIR Management Group▸ Product Strategist Orion Health▸ Blog: fhirblog.com▸ Tooling: clinFHIR.com

▸ Email: [email protected]


Todays Agenda

▸ What is FHIR (and why do we need it)▸ Basics of FHIR

– Resources– Profiling– Exchange (especially REST)

▸ Associated Standards– Security– SMART– CDS Hooks

▸ More info▸ Goal is to make you want to look further!


Why Interoperability?

▸ Health information sharing is important– Individuals involved in delivering care to patients now expect the

information they require to be available at the point of care▸ Data collected in multiple places

– Realistically need to move information around▸ Need to involve patients in care▸ Interfaces are expensive

– Especially if not standards based


Why FHIR?

In 2011, the Board of HL7 noted:

‣ Interoperability requirements are increasing‣ Need for real time access (API)

- Mobile‣ Vast increase in the amount, type and source of data

- e.g. Devices, Genomics‣ Analytics, population health‣ Implementer expectations

Existing standards were lacking, a fresh look was needed…


Overview of FHIR

▸ Fast Healthcare Interoperability Resources (FHIR)▸ Consistent, simple to use content model (resources)

– Controlled extensibility▸ Supports all paradigms of exchange

– Well thought out, standardized APIs– Documents & Messages

▸ Designed with implementers in mind▸ Detailed on-line, hyperlinked specification▸ Strong endorsement and support from vendors, providers

and regulatory community ▸ Vast, International community

http://hl7.org/fhir/index.html


Advantages for Implementers and Vendors

▸ Familiar tooling and technologies– XML/JSON, HTTP, REST, SSL, OAuth2

▸ Predefined resources and APIs – Domain knowledge is not required– Allows implementer to focus on the core application functionality

▸ Extensive on-line documentation, examples and reference server implementations▸ Open Source code libraries

– HAPI (Java) and Furore (.Net)▸ Test servers▸ Mobile friendly▸ Active and supportive community

Increases commercial viability of app development as FHIR compliant apps will work with different FHIR Servers (EMRs, HIEs)


FHIR timeline

2012 20162014 2018 2020

FirstDraft

2011 20152013 2017 2019

1st

DSTU2nd

STU~ 1st

Norm.~ 2nd

Norm.. . .

FreshLook

3rd

STU

FMM

FHIR:THE BASICS

1. Content2. Exchange3. Profiling


1. Content: Scope of specification - hl7.org/FHIR. (http://build.fhir.org/)


Modules


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


Clinical Resources

GeneralAllergyIntolerance

Condition (Problem)Procedure

ClinicalImpressionFamilyMemberHistory

RiskAssessmentDetectedIssue

Care ProvisionCarePlan

GoalReferralRequest

ProcedureRequestNutritionOrder

VisionPrescription

Medication & Immunization

MedicationMedicationOrder

MedicationAdministrationMedicationDispenseMedicationStatement

ImmunizationImmunizationRecommendation

DiagnosticsObservation

DiagnosticReportDiagnosticOrder

Specimen BodySite

ImagingStudy

Clinical

http://hl7.org/fhir/resourcelist.html


The resource ‘type’ in the specification (http://hl7.org/fhir/patient.html)


Resource example

Resource Identity & Metadata

Human Readable Summary

Extension with URL to definition

Standard Data:• MRN• Name• Gender• Birth Date• Provider

JSON also supported


References between resources

Coded PropertiestypebodySuiteindicationperformer.rolecomplicationrelatedItem.type

Other Propertiesidentifier (Identifier)outcome (String)

PROCEDURE

PATIENT

DIAGNOSTIC REPORTCONDITION

Subject

ReportRelated Item

Encounter Performer

ENCOUNTER PRACTITIONER


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 100.4°F 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


Encounter

Encounter

Practitioner

Patient

Asserter

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 100.4°F

Inflamed right drum

Urticarial Rash

Amoxicillin 250mg

Erythromycin 250mg

Penicillin Allergy


2. Adapting FHIR to your needs: Profiling

▸ Many different contexts in healthcare, but want a single set of Resources▸ 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 repository– 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


Profiling a resource | for example…

Note: Limited mandatory elements in the core spec

Require that the identifier uses the medicare number – and is required

Limit names to just 1 (instead of 0..*)

Change maritalStatusto another set of codes that extends the one from HL7 international

Add an extension to support ethnicity

Don’t support photo


3. Exchange: Paradigms

REST Documents

Messages Services(Operations)


REST (API)

▸ “Representational State Transfer” – an architecture for how to connect systems in real time

▸ Uses HTTP/S▸ Simple to use▸ Very commonly used outside of healthcare – especially mobile

– JASON report called out the lack of an API▸ For simple interactions

– Create– Read (& Query)– Update – Delete

▸ A lot of tooling / experience availablehttp://hl7.org/fhir/http.html


Mapping to verbs

create 2.1.10 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 [service-url]/[resourcetype] (?_format=mimeType) read 2.1.6

The read interaction accesses the current contents of a resource. The interaction is performed by an HTTP GET operation as shown:

GET [service-url]/[resourcetype]/{id} (?_format=mimeType) update 2.1.8

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 [service-url]/[resourcetype]/{id} (?_format=mimeType) delete 2.1.9

The delete interaction removes an existing resource. The interaction is performed by an HTTP DELETE operation as shown (note logical delete & versioning):

DELETE [service-url]/[resourcetype]/{id}


More advanced API

▸ Version aware updates▸ Conditional create / update▸ Partial update▸ Batch / Transactions▸ Subscription▸ OperationOutcome resource▸ Search (http://hl7.org/fhir/search.html)

– Bundle resource– Search parameters

• combining parameters - and/or• chaining• _include• _query


CapabilityStatement resource

▸ What can a server do:• Which FHIR version?• Which Resources?

• What operations against those resources?• What formats (XML/JSON)?• Is history supported?

• General Information• Who can I contact?• What’s the name of the software?


Services / Operations

▸ For more complex server side logic– OperationDefinition

▸ Real-time or async▸ Key part of ecosystem▸ E.g.

– Prescribing with Decision Support– Terminology– Immunization protocols


Documents and Messages


Regardless of paradigm, the content is the same

FHIRRepository

Document


FHIR Security & Privacy

▸ Not part of core spec– Highly specialized– Much existing knowledge / systems– Many different environments

▸ Hooks– Security tags– Specific resources

• AuditEvent, Provenance, Consent▸ Recommendations

– http://www.hl7.org/implement/standards/fhir/security.html

– OAuth2 & SMART


OAuth2: a high level

An example implementation

APP

1. AUTHENTICATE AND GETACCESS TOKEN

2. MAKE FHIR QUERYINCLUDING ACCESS TOKEN

RESOURCE SERVER

EHR

AUTHORIZATIONSERVER

DATABASES

3. CHECK TOKEN

0. ESTABLISH RELATIONSHIPS


FHIR and SMART: enabling the ecosystem

FHIR API and Resources

Terminology

Registry Identity

Repository


Clinical Decision Support | CDS Hooks (http://cds-hooks.org/)

Database

Request Advice

Return Suggestion

1

3

2More data

Application SMART/FHIRClinical Decision Support

CDS Services


Learning FHIR: clinFHIR

▸ Developed as training tool▸ Evolving!▸ Main components

– Scenario Builder– Logical Modeler – CodeSystem Builder– ValueSet editor– Profile editor– Extension Definition editor

http://clinfhir.com


clinFHIR: http://clinfhir.com


When to start using FHIR

▸ Now!▸ Better than bespoke

– Even though not finished…▸ Build on decades (person centuries) of thought & experience▸ Already real world uses out there

– Australia– Lithuania– United States - Commonwell

▸ Access to community for advice– Contribute own experience


In Summary

▸ FHIR is the latest HL7 interoperability standard▸ Promises to revolutionize sharing of healthcare information▸ Enormous interest locally and internationally▸ It future-proofs your IT investment▸ Is not a silver bullet▸ FHIR is disruptive▸ FHIR IS in your future


▸ From HL7 – http://hl7.org/fhir/index.html– wiki.hl7.org/index.php?title=FHIR– http://www.fhir.org/

▸ Community– https://chat.fhir.org/– List server ([email protected] )– Stack Overflow (tag FHIR)

▸ Blogs– http://www.healthintersections.com.au/– https://fhirblog.com/– https://thefhirplace.com/

▸ Libraries– Java (http://hapifhir.io/)– C# (NuGet HL7.FHIR)

▸ Tooling– Forge (http://fhir.furore.com/Forge)– http://clinfhir.com/

▸ Test servers– http://wiki.hl7.org/index.php?title=Public

ly_Available_FHIR_Servers_for_testing▸ White papers – http://orionhealth.com

– FHIR - Sparking innovation in health information sharing

– FHIR – Ignites healthcare sharing

More information

Rhapsody® Integration Engine is intended only for the electronic transfer, storage, or display of medical device data, or the electronic conversion of such data from one format to another in accordance with a preset specification as specified in the product manual and/or related documentation. Rhapsody Integration Engine is not intended to be used for active patient monitoring, controlling or altering the functions or parameters

of any medical device, or any other purpose relating to data obtained directly or indirectly from a medical device other than the transfer, storage, and conversion of such data from one format to another in accordance with preset specifications. Orion Health makes no warranties and the functionality described within may change without notice.

ONC Health IT Certification (2014 Edition) Rhapsody Integration Engine and Rhapsody Connect attained 2014 Edition Modular Ambulatory EHR Certification and 2014 Edition Modular Inpatient EHR Certification from the ICSA Labs ONC Health IT Certification Program. This EHR Module is 2014 Edition compliant and has been certified by an ONC-ACB in accordance with the applicable certification criteria adopted by the

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