HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.

Amsterdam, November 20 - 22 | @HL7 @FirelyTeam | #fhirdevdays | www.devdays.com/us

FHIR Documents

René Spronk, trainer/training coordinator, Firely/Ringholm

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Agenda

• FHIR Documents – core components

• Document Profiling

• FHIR Exchange Patterns

• CDA and FHIR Documents

• Document Metadata / IHE XDS

• Documents v. Clinical Notes

This presentation is focused on FHIR Douments. Knowledge of the HL7 CDA standard is not required.

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FHIR Example: Narrative with low level of coding

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Text vs. Coding

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• Two extremes in today's data processing

• “Narrative text” vs. “Fields in a database”

• What’s the optimal hybrid mixture ?

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FHIR Documents

• Focus is on persistence

• No workflow involved

• other than post/retrieve document

• Need tight rules over authenticated content

• Want to communicate multiple resources with control over how data is presented

• Data spans multiple resources

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Adam Everyman use case - let’s document the follow-up Encounter

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Document Example – Adam Everyman

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Document Structure = a bundle

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The Composition resource

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Narrative

• Narrative text can be in several places

• Rules control how the document is presented (for humans) so the text has a consistent order:

• The subject resource, Patient.text

• The Composition resource, Composition.text

• All the section.text(s)

• The presentation of the document is called the 'attested content' of the document • For implications see “Document Presentation”

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

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FHIR Documents: Human interoperability guaranteed

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ACP on Clinical Documentation

• Structured data should be captured only where they are useful in care delivery or essential for quality assessment or reporting.

• .. where the data element cannot be readily abstracted from the note with sufficient accuracy by using natural language processing

Source (Jan. 2015): Clinical Documentation in the 21st Century: A Policy Position Paper From the

American College of Physicians, http://annals.org/data/Journals/AIM/0/0000605-201502030-00193.pdf

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<section>

<text>

</text>

<entry>

<reference value="Observation/12486"/>

<!– Observation: systolic = 120 --> </entry>

<entry>

<reference value=" Observation/86499"/>

<!– Observation: diasystolic = 80 --> </entry>

</section>

Generated text narrative is fully derived from structured content

Blood

Pressure 120 80

Database

... ...

systolicBP int

diastolicBP int

... ...

<status value="generated"/>

<div xmlns="http://www.w3.org/1999/xhtml">

<p>Blood pressure 120/80</p>

</div>

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<section>

<text>

<status value="additional"/>

<div xmlns="http://www.w3.org/1999/xhtml">

<p>Patient with onset of asthma

in his teens</p>

</div>

</text>

</section>

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Narrative based narrative is richer than structured content (‘additional’ information)

Database

... ...

familyHistory text

... ...

Family

History:

Patient with onset of

asthma in his teens

<entry>

<reference value=" Observation/12486"/>

<!- Observation: asthma -->

</entry>

</section>

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What are the “medical document principles” ?

• Persistence – A document continues to exist in an unaltered state

• Stewardship – A document is maintained by an organization entrusted with its care.

• Potential for authentication - A document is an assemblage of information that is intended to be legally authenticated.

• Context - A document establishes the default context for its contents.

• Wholeness - Authentication of a document applies to the whole and does not apply to portions of the document without the full context of the document.

• Human readability – A document is human readable.

Source: HL7 CDA specification

FHIR Documents certainly meet these criteria.

HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.

Document Profiling

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Document Profile

• Profile of the Composition resource

• Profiles of the section content

• StructureDefinition

• GraphDefinition

• Implementation Guide

• E.g. IPS, http://hl7.org/fhir/uv/ips/2018Sep/

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Composition structured and coded

Sections •Salutation

•Problem/Subjective

•History

•Physcial/Objective

•Diagnoses

•Epicrise

•Plan

•............

•Family History

•Past Medical History

•Admission diagnosis

•Nursing diagnosis

•Discharge diagnosis

coded entry (ICD 10)

HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.

FHIR Exchange Patterns

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Paradigms

• FHIR supports 4 exchange patterns

REST Documents

Messages Services

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When to avoid Documents?

•Need for workflow • Request/response, decision support

•Data is dynamic

• i.e. want view of data now, not at time of authorship

• Multiple contributors over time

•Resources need to be accessed/manipulated independently

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Exchange patterns - characteristics

Document

Persisting attested content

Rules for rendering

No workflow support

No dynamic data

Unit of work = * resources

REST

CRUD, lightweight

Client driven orchestration

Unit of work = single resource

‘Natural’ servers

Messaging

Event driven

Behavioral expectation

Always request/response Async option

Server driven orchestration

Stuff other than CRUD Unit of work = * resources

HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.

CDA and FHIR Documents

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CDA to FHIR

Document bridge

Hospital System A

FHIR

Documents

Note: Documents are compositions,

• No update semantics

• Context?

• Wholeness?

FHIR

Repository

FHIR

REST

FHIR Document

processor

CDA and FHIR

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Mapping

• FHIR Documents have a wider scope than CDA (e.g. subjects other than a patient)

• Made more complex by human-readable nature

• In FHIR presentation determined by author, not by user of the document (as is the case with CDA)

• Best practice

• CDA header to Composition mapping

• CDA Template to resource mapping

• CDA Narrative to XHTML mapping

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Mapping CDA to FHIR

• Mapping includes

• Profile of the Composition resource

• Mapping of CDA header to Composition

• High-level mapping of CDA templates to FHIR profiles

• Main interest in this mapping in the US

• C-CDA to FHIR, http://wiki.hl7.org/index.php?title=C-CDA_on_FHIR

• Comparison:

• http://hl7.org/fhir/comparison-cda.html

• Video:

• https://vimeo.com/141875366

HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.

Document Metadata / XDS

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DocumentReference • Describes a document; metadata of the document

Contains, or

references,

a document

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Matadata

• Mainly a mapping of FHIR Header data elements to DocumentReference data elements • However: they need not be the same on some cases; document

lifecycle status

• Rich Metadata is essential for document management (DMS applications, IHE XDS) • E.g. Query, access control, provenance

HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.

Document v. Clinical Notes

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Varying Formats of Clinical Notes

Text or XHTML

RTF or PDF or .doc

Mixed document: structured FHIR resources, and narrative

Slide courtesy of Michelle Miller / Brett Marquard

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DocumentReference – Mixed structure and narrative May have 2:

1 Binary Resource (e.g. C-CDA, text, PDF, rtf)

2 Composition (if there’s strutured content)

[base]/Binary

[base]/Composition

Slide courtesy of Michelle Miller / Brett Marquard

HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.

Summary

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Summary

• FHIR Documents

• The Document exchange mechanism should be used if the focus is on persistence, and on narrative which is the authenticated content.

• Functionality of CDA, and more.

• Profiling (Implemetation Guide) is a necessity

• DocumentReference resource

• DMS archives, IHE XDS, Clinical Notes

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Example: Discharge Letter for Adam Everyman

• XML + HTML View

• STU3 Example

• https://bit.ly/2lE4KQx (zip)

HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with per mission.

Amsterdam, November 20 - 22 | @HL7 @FirelyTeam | #fhirdevdays | www.devdays.com/us

FHIR Documents

René Spronk, trainer/training coordinator, Firely/Ringholm