FHIR - as a new currency of exchange in New Zealand

FHIR – the new currency and process of exchange

Dr. David HayChair HL7 New Zealand

Co-Chair FHIR Management GroupBoard Member HINZ

Member HISOInformation Architect, Orion Health

www.fhirblog.com

• HL7 New Zealand

Agenda

• A review of FHIR

• Evolving the Interoperability Reference Architecture with a FHIR focus

• A practical example

• What we should be doing now

A review of FHIR

• HL7 New Zealand

A brief history & current status

• Latest HL7 Interoperability Standard

• 2 years old

• Huge international interest– Vendors

– National Bodies

– Other SDOs

• Currently DSTU-1– DSTU-2 mid next year

• HL7 New Zealand

Use across all Paradigms

• Document– Discharge Summary

– Clinic Notes

– Ambulance summary

– Referral

• Message– Admin (‘ADT’)

– Lab results and orders

• REST– Mobile

– Real time access

• Service– Complex back end logic

– Decision support

REST

DocumentsMessages

Services

Same resources

across all paradigms

• HL7 New Zealand

REST

Client Server

Request

Response

HTTP/S

• HTTP– Verbs

– Headers

– Status Codes

• The way the web works…– Familiar to developers

– Lots of tools

• Examples:– Add (POST [server]/Patient)

– Retrieve (GET [server]/Patient/100)

– Update (PUT [server]/Patient/100)

– Search (GET [server]/Patient?name=eve)

• HL7 New Zealand

Resources

• “Resources” are:– A core part of FHIR

– Small logically discrete units of information

• Smallest unit “of interest” to healthcare

– Defined behaviour and meaning

– Known identity / location

• (usually)

• They’re the building blocks…

7

• HL7 New Zealand

Main Clinical resources

• Observation

• Condition (Problem)

• DiagnosticReport

• MedicationPrescription (and others)

• AdverseReaction / AllergyIntolerance

• Immunizations / ImmunizationRecommentation

• CarePlan

• Questionnaire / QuestionnireAnswers

• ReferralRequest

• ContraIndication

• RiskAssessment

• Assessment

• Alert

• HL7 New Zealand

Important Supporting Resources

• Patient

• Practitioner

• List

• Encounter / EpisodeOfCare

• Order / OrderResponse

• DocumentReference

• Appointment / AppointmentResponse / Availability / Slot / HealthcareService

• Provenance

• HL7 New Zealand

ResourceNarrative

Elements

Extensions Extensions

Structure of a Resource

Metadata

• HL7 New Zealand

• HL7 New Zealand

Resource as a bag of DataTypes

• HL7 New Zealand

References between resources

• HL7 New Zealand

Profiles

• Constrains a resource/s for a specific use case

• Where extension definitions are stored

• It’s a resource like any other– Can be queried/located like any other resource

– Profile registries easy

Resource Profile

Extension

The extension points to its profile

Can be (and probably are) on different servers

HTTP://server/Profile/nzpatient#iwi

• HL7 New Zealand

Other things about resources

• Collections (bundles)– Query result– Transactions– Documents– Messages

• Versioning• Tools

– XML Editor– REST client– Libraries– Test Servers

33, v12 – 2012-12-04

33, v13 – 2012-12-05

33, v14 – 2012-12-08

Patient/33/_history/12


33, v15 – 2012-12-09



Patient/33

Evolving the IRA with a FHIR focus

• HL7 New Zealand

Interoperability Reference Architecture

XDSCDA Archetypes

• HL7 New Zealand

CDA as the unit of exchange

• Move to FHIR documents– Timing – next year earliest (DSTU-2)

– Continue with simple CDA for a while

• Migrate current CDA designs straight forward– Closed nature of our design

– Create FHIR profiles of current specs

• Modify GP2GP toolkit to support FHIR documents– FHIR document to/from object interface

– Our CDA to/from FHIR documents

– Support combined CDA/FHIR documents

• Ultimately resources are the units of exchange– Moving beyond documents

• HL7 New Zealand

XDS (Record Locator)

• HL7 New Zealand

Archetypes

• Formal descriptions of clinical practice– Wide clinical input

– Peer reviewed

– Sophisticated tooling

• Use profiles to map requirements to FHIR– As with CDA -> FHIR or v2 -> FHIR

• Emphasize importance of standardizing profiles– FHIR resources are engineering

– Profiles represent clinical perspective

• HL7 New Zealand

Transition considerations

• If it ain’t broke…– Leave existing v2 messaging for now

• Though transformation should be straightforward

• National– Need Record Locator Service

• But with a FHIR façade – not ebXML

• Use Document metadata standard

– Need other infrastructure

• Profile registry

• OAuth2 / OpenID connect (SMART)

• FHIR enabled repositories (with Consumer access)

– Eg MLOM, Allergies

• Local– FHIR enable local systems (query at least)

• Example of Brett’s work with PMS

– Toolkit

Moving into clinical records:A practical example

• HL7 New Zealand

Moving beyond exchange

• Resources as basis of storing clinical notes

• Theme:– A mobile application for a clinician

– Collect and present clinical information about a patient

• Previous encounters

• Lab Data

• Documents

– Record details of an encounter

– Schedule encounters

– Make orders for Labs, meds etc.

– Get Decision support

– Save a summary in a Document Repository

• HL7 New Zealand

The app

• Not considering:– Security

– App architecture

– Other infrastructure

• HL7 New Zealand

Clinical Scenario

• First consultation– Complaining of pain in the r) ear for 3 days with an

elevated temperature. On examination, temperature 38.5 degrees and an inflamed r) ear drum with no perforation. Diagnosis Otitis Media, and prescribed Amoxil 250mg TDS for 5 days

• Follow up consultation– 5 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 and advised not to take penicillin in the future.

Condition

Observation

Med

Adv Rean.

Allergy

Encounter

5 year old boyPatient

• HL7 New Zealand

Looking at the relationships

• HL7 New Zealand

Creating a summary document

What should we be doing now

• HL7 New Zealand

Practical next steps

• Form a local community– Multi-discipline

– FHIR is coming, it’s not ‘IF’ any more…

• Learn the specification– It’s very readable

– Play with the test servers

• Profiles and archetypes

• CDA to FHIR documents– The babelFish (toolkit)

– Design work

Thanks for listening!

• Stand up test services– Record Locator Service

– FHIR repositories

– Security infrastructure

– Profile registries

• Support innovation – and innovators– Clinicians Challenge version 2?

– Especially mobile

FHIR - as a new currency of exchange in New Zealand

Healthcare

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