Training session: Clinical Document Architecture (CDA) and ... · Training session: Clinical...

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Training session: Clinical Document Architecture (CDA) and Fast Healthcare Interoperability Resources (FHIR), introduction, comparison and best practices Νίκος Κυριακουλάκος Υπεύθυνος Προτύπων HL7 Hellas, CTO Apollo SA Αθήνα, 26 Οκτωβρίου 2015

Transcript of Training session: Clinical Document Architecture (CDA) and ... · Training session: Clinical...

Training session Clinical Document Architecture (CDA)

and Fast Healthcare Interoperability Resources (FHIR)

introduction comparison and best practices

Νίκος Κυριακουλάκος

Υπεύθυνος Προτύπων HL7 Hellas CTO Apollo SA

Αθήνα 26 Οκτωβρίου 2015

Agenda Ο Διεθνής Οργανισμός HL7

HL7 Hellas

Τα πρότυπα του HL7 HL7 v2x

HL7 EHR-S

HL7 v3 RIM

HL7 CDA CDA in Details

CDA Templates Implementation Guides Cases

Art-Deacutecor

HL7 FHIR FHIR in Details

FHIR Building blocks ndash Resources

FHIR Development

FHIR vs CDA

Ερωτήσεις ndash Περαιτέρω ανάλυση

HL7 International

Ο Οργανισμός HL7 ANSI-approved Standards Developing Organisation (SDO)

Μη κερδοσκοπικός οργανισμός

gt2200 μέλη

gt500 εταιρίες μέλη

Αναπτύσσει και παρέχει πρότυπα κυρίως για ανταλλαγή ιατρικών

δεδομένων

Περιλαμβάνει το 90 από τις μεγαλύτερες εταιρίας συστημάτων

Ιατρικής Πληροφορικής

Παραρτήματα σε περισσότερες από 40 χώρες

Ευρώπη ndash HL7 Europe Office wwwhl7eu

wwwhl7org

Το HL7 Hellas

Ιδρύθηκε το 2003 (επίσημο HL7 παράρτημα στην

Ελλάδα -International Affiliate)

Μέλη του (φυσικά amp νομικά πρόσωπα) Εταιρίες με συστήματα πληροφορικής στο χώρο της υγείας

Πανεπιστήμια

Ερευνητικά Ιδρύματα

Φυσικά πρόσωπα

wwwhl7orggr

HL7 is more than you think

ISO certified series of standards - Examples ISOHL7 107812009 = HL7 Electronic Health Record-System Functional Model

Release 11

ISOHL7 279322009 = HL7 Clinical Document Architecture Release 2

ISOHL7 217312014 = HL7 version 3 -- Reference information model -- Release

4

ISOHL7 279512009 = HL7 Common terminology services release 1

ISOHL7 279312009 = HL7 Version 25 -- An application protocol for electronic

data exchange in healthcare environments

ISOHL7 27953-22011 = HL7 Individual case safety reports (ICSRs) in

pharmacovigilance -- Part 2 Human pharmaceutical reporting requirements for

ICSR

HL7 mission Ensure interoperability between information systems in order to

achieve

Best treatment and health prevention

Integration of procedures in healthcare

Improvement and quality assurance of medical data

Knowledge exchange between all involved stakeholders

4 interoperability methods

Messaging interface (HL7 v2x)

Interfaces through web services (SOA web-services) (HL7 v3)

XML Structured file exchange (HL7 CDA R2)

Data exchange focusing on mobile apps (Web Methods ndash REST ndash JSON) (HL7

FHIR)

HL7 Standards timeline

2013 HL7 makes standards

available under free license

HL7 Standards Types

Healthcare-related datainformationrouting Standards Messaging Standards (V2x V3 FHIR)

Document Standards (CDA)

Healthcare-related Functional Standards (EHR-S FM)

Other Standards (CCOW Vocabulary Security

Healthcare Devices etc)

HL7 Messaging Standards

HL7 v2x

ADT lt-gt LIS

LIS

LIS

ADT

ADT

ORM - gt

ORR - gt

ACK - gt

ORU - gt

LIS message sample v2x

EHR-S Functional Model Standard

Ένα πολύ σημαντικό βήμα για να οριστεί και πιστοποιηθεί ένα

σύστημα ΗΦΥ (EHR)

Το EHR-S FM αναπαριστά ένα υπερσύνολο από λειτουργίες για ένα

σύστημα ΗΦΥ (EHR)

Περιγράφει σημαντικά χαρακτηριστικά και λειτουργίες που θα

πρέπει να περιέχονται σε ένα σύστημα ΗΦΥ

Παραθέτει μια λίστα από λειτουργίες στις οποίες το κάθε κριτήριο

χαρακτηρίζεται σαν laquoSHALLraquo laquoSHOULDraquo ή laquoMAYraquo

Δημιουργεί μια κοινή πλατφόρμα για τους παρόχους τους

προμηθευτές και άλλους εμπλεκόμενους για να περιγράψει την

απαραίτητη λειτουργικότητα του ΗΦΥ

EHR-S Functional Model Standard Έχει δημιουργηθεί από την αρχή με διεθνή χαρακτηριστικά

Χαρακτηρίζεται από ευελιξία για να διαφοροποιούνται οι

υλοποιήσεις

Είναι εναρμονισμένο με laquoπαρόμοιεςraquo προσπάθειες στο

χώρο της υγείας όπως Committee eacute Europeacuteen de Normalisation (CEN 13606)

Institute Of Medicine

openEHR

ISOTC 215 International Standards Organization

Technical Specification 18308

ASTM E31

Περιέχει ~ 160 Λειτουργίες και ~1000 κριτήρια συμόρφωσης

Διαθέσιμο στο διαδίκτυο httpwwwhl7orgehr

Άξονες Βασικών Λειτουργιών EHR-S FM

Source HL7 EHR-S FM Overview Chapter

Άμεση Φροντίδα

Υποστηρικτικές Λειτουργίες

Πληροφοριακές Υποδομές

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Agenda Ο Διεθνής Οργανισμός HL7

HL7 Hellas

Τα πρότυπα του HL7 HL7 v2x

HL7 EHR-S

HL7 v3 RIM

HL7 CDA CDA in Details

CDA Templates Implementation Guides Cases

Art-Deacutecor

HL7 FHIR FHIR in Details

FHIR Building blocks ndash Resources

FHIR Development

FHIR vs CDA

Ερωτήσεις ndash Περαιτέρω ανάλυση

HL7 International

Ο Οργανισμός HL7 ANSI-approved Standards Developing Organisation (SDO)

Μη κερδοσκοπικός οργανισμός

gt2200 μέλη

gt500 εταιρίες μέλη

Αναπτύσσει και παρέχει πρότυπα κυρίως για ανταλλαγή ιατρικών

δεδομένων

Περιλαμβάνει το 90 από τις μεγαλύτερες εταιρίας συστημάτων

Ιατρικής Πληροφορικής

Παραρτήματα σε περισσότερες από 40 χώρες

Ευρώπη ndash HL7 Europe Office wwwhl7eu

wwwhl7org

Το HL7 Hellas

Ιδρύθηκε το 2003 (επίσημο HL7 παράρτημα στην

Ελλάδα -International Affiliate)

Μέλη του (φυσικά amp νομικά πρόσωπα) Εταιρίες με συστήματα πληροφορικής στο χώρο της υγείας

Πανεπιστήμια

Ερευνητικά Ιδρύματα

Φυσικά πρόσωπα

wwwhl7orggr

HL7 is more than you think

ISO certified series of standards - Examples ISOHL7 107812009 = HL7 Electronic Health Record-System Functional Model

Release 11

ISOHL7 279322009 = HL7 Clinical Document Architecture Release 2

ISOHL7 217312014 = HL7 version 3 -- Reference information model -- Release

4

ISOHL7 279512009 = HL7 Common terminology services release 1

ISOHL7 279312009 = HL7 Version 25 -- An application protocol for electronic

data exchange in healthcare environments

ISOHL7 27953-22011 = HL7 Individual case safety reports (ICSRs) in

pharmacovigilance -- Part 2 Human pharmaceutical reporting requirements for

ICSR

HL7 mission Ensure interoperability between information systems in order to

achieve

Best treatment and health prevention

Integration of procedures in healthcare

Improvement and quality assurance of medical data

Knowledge exchange between all involved stakeholders

4 interoperability methods

Messaging interface (HL7 v2x)

Interfaces through web services (SOA web-services) (HL7 v3)

XML Structured file exchange (HL7 CDA R2)

Data exchange focusing on mobile apps (Web Methods ndash REST ndash JSON) (HL7

FHIR)

HL7 Standards timeline

2013 HL7 makes standards

available under free license

HL7 Standards Types

Healthcare-related datainformationrouting Standards Messaging Standards (V2x V3 FHIR)

Document Standards (CDA)

Healthcare-related Functional Standards (EHR-S FM)

Other Standards (CCOW Vocabulary Security

Healthcare Devices etc)

HL7 Messaging Standards

HL7 v2x

ADT lt-gt LIS

LIS

LIS

ADT

ADT

ORM - gt

ORR - gt

ACK - gt

ORU - gt

LIS message sample v2x

EHR-S Functional Model Standard

Ένα πολύ σημαντικό βήμα για να οριστεί και πιστοποιηθεί ένα

σύστημα ΗΦΥ (EHR)

Το EHR-S FM αναπαριστά ένα υπερσύνολο από λειτουργίες για ένα

σύστημα ΗΦΥ (EHR)

Περιγράφει σημαντικά χαρακτηριστικά και λειτουργίες που θα

πρέπει να περιέχονται σε ένα σύστημα ΗΦΥ

Παραθέτει μια λίστα από λειτουργίες στις οποίες το κάθε κριτήριο

χαρακτηρίζεται σαν laquoSHALLraquo laquoSHOULDraquo ή laquoMAYraquo

Δημιουργεί μια κοινή πλατφόρμα για τους παρόχους τους

προμηθευτές και άλλους εμπλεκόμενους για να περιγράψει την

απαραίτητη λειτουργικότητα του ΗΦΥ

EHR-S Functional Model Standard Έχει δημιουργηθεί από την αρχή με διεθνή χαρακτηριστικά

Χαρακτηρίζεται από ευελιξία για να διαφοροποιούνται οι

υλοποιήσεις

Είναι εναρμονισμένο με laquoπαρόμοιεςraquo προσπάθειες στο

χώρο της υγείας όπως Committee eacute Europeacuteen de Normalisation (CEN 13606)

Institute Of Medicine

openEHR

ISOTC 215 International Standards Organization

Technical Specification 18308

ASTM E31

Περιέχει ~ 160 Λειτουργίες και ~1000 κριτήρια συμόρφωσης

Διαθέσιμο στο διαδίκτυο httpwwwhl7orgehr

Άξονες Βασικών Λειτουργιών EHR-S FM

Source HL7 EHR-S FM Overview Chapter

Άμεση Φροντίδα

Υποστηρικτικές Λειτουργίες

Πληροφοριακές Υποδομές

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 International

Ο Οργανισμός HL7 ANSI-approved Standards Developing Organisation (SDO)

Μη κερδοσκοπικός οργανισμός

gt2200 μέλη

gt500 εταιρίες μέλη

Αναπτύσσει και παρέχει πρότυπα κυρίως για ανταλλαγή ιατρικών

δεδομένων

Περιλαμβάνει το 90 από τις μεγαλύτερες εταιρίας συστημάτων

Ιατρικής Πληροφορικής

Παραρτήματα σε περισσότερες από 40 χώρες

Ευρώπη ndash HL7 Europe Office wwwhl7eu

wwwhl7org

Το HL7 Hellas

Ιδρύθηκε το 2003 (επίσημο HL7 παράρτημα στην

Ελλάδα -International Affiliate)

Μέλη του (φυσικά amp νομικά πρόσωπα) Εταιρίες με συστήματα πληροφορικής στο χώρο της υγείας

Πανεπιστήμια

Ερευνητικά Ιδρύματα

Φυσικά πρόσωπα

wwwhl7orggr

HL7 is more than you think

ISO certified series of standards - Examples ISOHL7 107812009 = HL7 Electronic Health Record-System Functional Model

Release 11

ISOHL7 279322009 = HL7 Clinical Document Architecture Release 2

ISOHL7 217312014 = HL7 version 3 -- Reference information model -- Release

4

ISOHL7 279512009 = HL7 Common terminology services release 1

ISOHL7 279312009 = HL7 Version 25 -- An application protocol for electronic

data exchange in healthcare environments

ISOHL7 27953-22011 = HL7 Individual case safety reports (ICSRs) in

pharmacovigilance -- Part 2 Human pharmaceutical reporting requirements for

ICSR

HL7 mission Ensure interoperability between information systems in order to

achieve

Best treatment and health prevention

Integration of procedures in healthcare

Improvement and quality assurance of medical data

Knowledge exchange between all involved stakeholders

4 interoperability methods

Messaging interface (HL7 v2x)

Interfaces through web services (SOA web-services) (HL7 v3)

XML Structured file exchange (HL7 CDA R2)

Data exchange focusing on mobile apps (Web Methods ndash REST ndash JSON) (HL7

FHIR)

HL7 Standards timeline

2013 HL7 makes standards

available under free license

HL7 Standards Types

Healthcare-related datainformationrouting Standards Messaging Standards (V2x V3 FHIR)

Document Standards (CDA)

Healthcare-related Functional Standards (EHR-S FM)

Other Standards (CCOW Vocabulary Security

Healthcare Devices etc)

HL7 Messaging Standards

HL7 v2x

ADT lt-gt LIS

LIS

LIS

ADT

ADT

ORM - gt

ORR - gt

ACK - gt

ORU - gt

LIS message sample v2x

EHR-S Functional Model Standard

Ένα πολύ σημαντικό βήμα για να οριστεί και πιστοποιηθεί ένα

σύστημα ΗΦΥ (EHR)

Το EHR-S FM αναπαριστά ένα υπερσύνολο από λειτουργίες για ένα

σύστημα ΗΦΥ (EHR)

Περιγράφει σημαντικά χαρακτηριστικά και λειτουργίες που θα

πρέπει να περιέχονται σε ένα σύστημα ΗΦΥ

Παραθέτει μια λίστα από λειτουργίες στις οποίες το κάθε κριτήριο

χαρακτηρίζεται σαν laquoSHALLraquo laquoSHOULDraquo ή laquoMAYraquo

Δημιουργεί μια κοινή πλατφόρμα για τους παρόχους τους

προμηθευτές και άλλους εμπλεκόμενους για να περιγράψει την

απαραίτητη λειτουργικότητα του ΗΦΥ

EHR-S Functional Model Standard Έχει δημιουργηθεί από την αρχή με διεθνή χαρακτηριστικά

Χαρακτηρίζεται από ευελιξία για να διαφοροποιούνται οι

υλοποιήσεις

Είναι εναρμονισμένο με laquoπαρόμοιεςraquo προσπάθειες στο

χώρο της υγείας όπως Committee eacute Europeacuteen de Normalisation (CEN 13606)

Institute Of Medicine

openEHR

ISOTC 215 International Standards Organization

Technical Specification 18308

ASTM E31

Περιέχει ~ 160 Λειτουργίες και ~1000 κριτήρια συμόρφωσης

Διαθέσιμο στο διαδίκτυο httpwwwhl7orgehr

Άξονες Βασικών Λειτουργιών EHR-S FM

Source HL7 EHR-S FM Overview Chapter

Άμεση Φροντίδα

Υποστηρικτικές Λειτουργίες

Πληροφοριακές Υποδομές

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Ο Οργανισμός HL7 ANSI-approved Standards Developing Organisation (SDO)

Μη κερδοσκοπικός οργανισμός

gt2200 μέλη

gt500 εταιρίες μέλη

Αναπτύσσει και παρέχει πρότυπα κυρίως για ανταλλαγή ιατρικών

δεδομένων

Περιλαμβάνει το 90 από τις μεγαλύτερες εταιρίας συστημάτων

Ιατρικής Πληροφορικής

Παραρτήματα σε περισσότερες από 40 χώρες

Ευρώπη ndash HL7 Europe Office wwwhl7eu

wwwhl7org

Το HL7 Hellas

Ιδρύθηκε το 2003 (επίσημο HL7 παράρτημα στην

Ελλάδα -International Affiliate)

Μέλη του (φυσικά amp νομικά πρόσωπα) Εταιρίες με συστήματα πληροφορικής στο χώρο της υγείας

Πανεπιστήμια

Ερευνητικά Ιδρύματα

Φυσικά πρόσωπα

wwwhl7orggr

HL7 is more than you think

ISO certified series of standards - Examples ISOHL7 107812009 = HL7 Electronic Health Record-System Functional Model

Release 11

ISOHL7 279322009 = HL7 Clinical Document Architecture Release 2

ISOHL7 217312014 = HL7 version 3 -- Reference information model -- Release

4

ISOHL7 279512009 = HL7 Common terminology services release 1

ISOHL7 279312009 = HL7 Version 25 -- An application protocol for electronic

data exchange in healthcare environments

ISOHL7 27953-22011 = HL7 Individual case safety reports (ICSRs) in

pharmacovigilance -- Part 2 Human pharmaceutical reporting requirements for

ICSR

HL7 mission Ensure interoperability between information systems in order to

achieve

Best treatment and health prevention

Integration of procedures in healthcare

Improvement and quality assurance of medical data

Knowledge exchange between all involved stakeholders

4 interoperability methods

Messaging interface (HL7 v2x)

Interfaces through web services (SOA web-services) (HL7 v3)

XML Structured file exchange (HL7 CDA R2)

Data exchange focusing on mobile apps (Web Methods ndash REST ndash JSON) (HL7

FHIR)

HL7 Standards timeline

2013 HL7 makes standards

available under free license

HL7 Standards Types

Healthcare-related datainformationrouting Standards Messaging Standards (V2x V3 FHIR)

Document Standards (CDA)

Healthcare-related Functional Standards (EHR-S FM)

Other Standards (CCOW Vocabulary Security

Healthcare Devices etc)

HL7 Messaging Standards

HL7 v2x

ADT lt-gt LIS

LIS

LIS

ADT

ADT

ORM - gt

ORR - gt

ACK - gt

ORU - gt

LIS message sample v2x

EHR-S Functional Model Standard

Ένα πολύ σημαντικό βήμα για να οριστεί και πιστοποιηθεί ένα

σύστημα ΗΦΥ (EHR)

Το EHR-S FM αναπαριστά ένα υπερσύνολο από λειτουργίες για ένα

σύστημα ΗΦΥ (EHR)

Περιγράφει σημαντικά χαρακτηριστικά και λειτουργίες που θα

πρέπει να περιέχονται σε ένα σύστημα ΗΦΥ

Παραθέτει μια λίστα από λειτουργίες στις οποίες το κάθε κριτήριο

χαρακτηρίζεται σαν laquoSHALLraquo laquoSHOULDraquo ή laquoMAYraquo

Δημιουργεί μια κοινή πλατφόρμα για τους παρόχους τους

προμηθευτές και άλλους εμπλεκόμενους για να περιγράψει την

απαραίτητη λειτουργικότητα του ΗΦΥ

EHR-S Functional Model Standard Έχει δημιουργηθεί από την αρχή με διεθνή χαρακτηριστικά

Χαρακτηρίζεται από ευελιξία για να διαφοροποιούνται οι

υλοποιήσεις

Είναι εναρμονισμένο με laquoπαρόμοιεςraquo προσπάθειες στο

χώρο της υγείας όπως Committee eacute Europeacuteen de Normalisation (CEN 13606)

Institute Of Medicine

openEHR

ISOTC 215 International Standards Organization

Technical Specification 18308

ASTM E31

Περιέχει ~ 160 Λειτουργίες και ~1000 κριτήρια συμόρφωσης

Διαθέσιμο στο διαδίκτυο httpwwwhl7orgehr

Άξονες Βασικών Λειτουργιών EHR-S FM

Source HL7 EHR-S FM Overview Chapter

Άμεση Φροντίδα

Υποστηρικτικές Λειτουργίες

Πληροφοριακές Υποδομές

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Το HL7 Hellas

Ιδρύθηκε το 2003 (επίσημο HL7 παράρτημα στην

Ελλάδα -International Affiliate)

Μέλη του (φυσικά amp νομικά πρόσωπα) Εταιρίες με συστήματα πληροφορικής στο χώρο της υγείας

Πανεπιστήμια

Ερευνητικά Ιδρύματα

Φυσικά πρόσωπα

wwwhl7orggr

HL7 is more than you think

ISO certified series of standards - Examples ISOHL7 107812009 = HL7 Electronic Health Record-System Functional Model

Release 11

ISOHL7 279322009 = HL7 Clinical Document Architecture Release 2

ISOHL7 217312014 = HL7 version 3 -- Reference information model -- Release

4

ISOHL7 279512009 = HL7 Common terminology services release 1

ISOHL7 279312009 = HL7 Version 25 -- An application protocol for electronic

data exchange in healthcare environments

ISOHL7 27953-22011 = HL7 Individual case safety reports (ICSRs) in

pharmacovigilance -- Part 2 Human pharmaceutical reporting requirements for

ICSR

HL7 mission Ensure interoperability between information systems in order to

achieve

Best treatment and health prevention

Integration of procedures in healthcare

Improvement and quality assurance of medical data

Knowledge exchange between all involved stakeholders

4 interoperability methods

Messaging interface (HL7 v2x)

Interfaces through web services (SOA web-services) (HL7 v3)

XML Structured file exchange (HL7 CDA R2)

Data exchange focusing on mobile apps (Web Methods ndash REST ndash JSON) (HL7

FHIR)

HL7 Standards timeline

2013 HL7 makes standards

available under free license

HL7 Standards Types

Healthcare-related datainformationrouting Standards Messaging Standards (V2x V3 FHIR)

Document Standards (CDA)

Healthcare-related Functional Standards (EHR-S FM)

Other Standards (CCOW Vocabulary Security

Healthcare Devices etc)

HL7 Messaging Standards

HL7 v2x

ADT lt-gt LIS

LIS

LIS

ADT

ADT

ORM - gt

ORR - gt

ACK - gt

ORU - gt

LIS message sample v2x

EHR-S Functional Model Standard

Ένα πολύ σημαντικό βήμα για να οριστεί και πιστοποιηθεί ένα

σύστημα ΗΦΥ (EHR)

Το EHR-S FM αναπαριστά ένα υπερσύνολο από λειτουργίες για ένα

σύστημα ΗΦΥ (EHR)

Περιγράφει σημαντικά χαρακτηριστικά και λειτουργίες που θα

πρέπει να περιέχονται σε ένα σύστημα ΗΦΥ

Παραθέτει μια λίστα από λειτουργίες στις οποίες το κάθε κριτήριο

χαρακτηρίζεται σαν laquoSHALLraquo laquoSHOULDraquo ή laquoMAYraquo

Δημιουργεί μια κοινή πλατφόρμα για τους παρόχους τους

προμηθευτές και άλλους εμπλεκόμενους για να περιγράψει την

απαραίτητη λειτουργικότητα του ΗΦΥ

EHR-S Functional Model Standard Έχει δημιουργηθεί από την αρχή με διεθνή χαρακτηριστικά

Χαρακτηρίζεται από ευελιξία για να διαφοροποιούνται οι

υλοποιήσεις

Είναι εναρμονισμένο με laquoπαρόμοιεςraquo προσπάθειες στο

χώρο της υγείας όπως Committee eacute Europeacuteen de Normalisation (CEN 13606)

Institute Of Medicine

openEHR

ISOTC 215 International Standards Organization

Technical Specification 18308

ASTM E31

Περιέχει ~ 160 Λειτουργίες και ~1000 κριτήρια συμόρφωσης

Διαθέσιμο στο διαδίκτυο httpwwwhl7orgehr

Άξονες Βασικών Λειτουργιών EHR-S FM

Source HL7 EHR-S FM Overview Chapter

Άμεση Φροντίδα

Υποστηρικτικές Λειτουργίες

Πληροφοριακές Υποδομές

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 is more than you think

ISO certified series of standards - Examples ISOHL7 107812009 = HL7 Electronic Health Record-System Functional Model

Release 11

ISOHL7 279322009 = HL7 Clinical Document Architecture Release 2

ISOHL7 217312014 = HL7 version 3 -- Reference information model -- Release

4

ISOHL7 279512009 = HL7 Common terminology services release 1

ISOHL7 279312009 = HL7 Version 25 -- An application protocol for electronic

data exchange in healthcare environments

ISOHL7 27953-22011 = HL7 Individual case safety reports (ICSRs) in

pharmacovigilance -- Part 2 Human pharmaceutical reporting requirements for

ICSR

HL7 mission Ensure interoperability between information systems in order to

achieve

Best treatment and health prevention

Integration of procedures in healthcare

Improvement and quality assurance of medical data

Knowledge exchange between all involved stakeholders

4 interoperability methods

Messaging interface (HL7 v2x)

Interfaces through web services (SOA web-services) (HL7 v3)

XML Structured file exchange (HL7 CDA R2)

Data exchange focusing on mobile apps (Web Methods ndash REST ndash JSON) (HL7

FHIR)

HL7 Standards timeline

2013 HL7 makes standards

available under free license

HL7 Standards Types

Healthcare-related datainformationrouting Standards Messaging Standards (V2x V3 FHIR)

Document Standards (CDA)

Healthcare-related Functional Standards (EHR-S FM)

Other Standards (CCOW Vocabulary Security

Healthcare Devices etc)

HL7 Messaging Standards

HL7 v2x

ADT lt-gt LIS

LIS

LIS

ADT

ADT

ORM - gt

ORR - gt

ACK - gt

ORU - gt

LIS message sample v2x

EHR-S Functional Model Standard

Ένα πολύ σημαντικό βήμα για να οριστεί και πιστοποιηθεί ένα

σύστημα ΗΦΥ (EHR)

Το EHR-S FM αναπαριστά ένα υπερσύνολο από λειτουργίες για ένα

σύστημα ΗΦΥ (EHR)

Περιγράφει σημαντικά χαρακτηριστικά και λειτουργίες που θα

πρέπει να περιέχονται σε ένα σύστημα ΗΦΥ

Παραθέτει μια λίστα από λειτουργίες στις οποίες το κάθε κριτήριο

χαρακτηρίζεται σαν laquoSHALLraquo laquoSHOULDraquo ή laquoMAYraquo

Δημιουργεί μια κοινή πλατφόρμα για τους παρόχους τους

προμηθευτές και άλλους εμπλεκόμενους για να περιγράψει την

απαραίτητη λειτουργικότητα του ΗΦΥ

EHR-S Functional Model Standard Έχει δημιουργηθεί από την αρχή με διεθνή χαρακτηριστικά

Χαρακτηρίζεται από ευελιξία για να διαφοροποιούνται οι

υλοποιήσεις

Είναι εναρμονισμένο με laquoπαρόμοιεςraquo προσπάθειες στο

χώρο της υγείας όπως Committee eacute Europeacuteen de Normalisation (CEN 13606)

Institute Of Medicine

openEHR

ISOTC 215 International Standards Organization

Technical Specification 18308

ASTM E31

Περιέχει ~ 160 Λειτουργίες και ~1000 κριτήρια συμόρφωσης

Διαθέσιμο στο διαδίκτυο httpwwwhl7orgehr

Άξονες Βασικών Λειτουργιών EHR-S FM

Source HL7 EHR-S FM Overview Chapter

Άμεση Φροντίδα

Υποστηρικτικές Λειτουργίες

Πληροφοριακές Υποδομές

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 mission Ensure interoperability between information systems in order to

achieve

Best treatment and health prevention

Integration of procedures in healthcare

Improvement and quality assurance of medical data

Knowledge exchange between all involved stakeholders

4 interoperability methods

Messaging interface (HL7 v2x)

Interfaces through web services (SOA web-services) (HL7 v3)

XML Structured file exchange (HL7 CDA R2)

Data exchange focusing on mobile apps (Web Methods ndash REST ndash JSON) (HL7

FHIR)

HL7 Standards timeline

2013 HL7 makes standards

available under free license

HL7 Standards Types

Healthcare-related datainformationrouting Standards Messaging Standards (V2x V3 FHIR)

Document Standards (CDA)

Healthcare-related Functional Standards (EHR-S FM)

Other Standards (CCOW Vocabulary Security

Healthcare Devices etc)

HL7 Messaging Standards

HL7 v2x

ADT lt-gt LIS

LIS

LIS

ADT

ADT

ORM - gt

ORR - gt

ACK - gt

ORU - gt

LIS message sample v2x

EHR-S Functional Model Standard

Ένα πολύ σημαντικό βήμα για να οριστεί και πιστοποιηθεί ένα

σύστημα ΗΦΥ (EHR)

Το EHR-S FM αναπαριστά ένα υπερσύνολο από λειτουργίες για ένα

σύστημα ΗΦΥ (EHR)

Περιγράφει σημαντικά χαρακτηριστικά και λειτουργίες που θα

πρέπει να περιέχονται σε ένα σύστημα ΗΦΥ

Παραθέτει μια λίστα από λειτουργίες στις οποίες το κάθε κριτήριο

χαρακτηρίζεται σαν laquoSHALLraquo laquoSHOULDraquo ή laquoMAYraquo

Δημιουργεί μια κοινή πλατφόρμα για τους παρόχους τους

προμηθευτές και άλλους εμπλεκόμενους για να περιγράψει την

απαραίτητη λειτουργικότητα του ΗΦΥ

EHR-S Functional Model Standard Έχει δημιουργηθεί από την αρχή με διεθνή χαρακτηριστικά

Χαρακτηρίζεται από ευελιξία για να διαφοροποιούνται οι

υλοποιήσεις

Είναι εναρμονισμένο με laquoπαρόμοιεςraquo προσπάθειες στο

χώρο της υγείας όπως Committee eacute Europeacuteen de Normalisation (CEN 13606)

Institute Of Medicine

openEHR

ISOTC 215 International Standards Organization

Technical Specification 18308

ASTM E31

Περιέχει ~ 160 Λειτουργίες και ~1000 κριτήρια συμόρφωσης

Διαθέσιμο στο διαδίκτυο httpwwwhl7orgehr

Άξονες Βασικών Λειτουργιών EHR-S FM

Source HL7 EHR-S FM Overview Chapter

Άμεση Φροντίδα

Υποστηρικτικές Λειτουργίες

Πληροφοριακές Υποδομές

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 Standards timeline

2013 HL7 makes standards

available under free license

HL7 Standards Types

Healthcare-related datainformationrouting Standards Messaging Standards (V2x V3 FHIR)

Document Standards (CDA)

Healthcare-related Functional Standards (EHR-S FM)

Other Standards (CCOW Vocabulary Security

Healthcare Devices etc)

HL7 Messaging Standards

HL7 v2x

ADT lt-gt LIS

LIS

LIS

ADT

ADT

ORM - gt

ORR - gt

ACK - gt

ORU - gt

LIS message sample v2x

EHR-S Functional Model Standard

Ένα πολύ σημαντικό βήμα για να οριστεί και πιστοποιηθεί ένα

σύστημα ΗΦΥ (EHR)

Το EHR-S FM αναπαριστά ένα υπερσύνολο από λειτουργίες για ένα

σύστημα ΗΦΥ (EHR)

Περιγράφει σημαντικά χαρακτηριστικά και λειτουργίες που θα

πρέπει να περιέχονται σε ένα σύστημα ΗΦΥ

Παραθέτει μια λίστα από λειτουργίες στις οποίες το κάθε κριτήριο

χαρακτηρίζεται σαν laquoSHALLraquo laquoSHOULDraquo ή laquoMAYraquo

Δημιουργεί μια κοινή πλατφόρμα για τους παρόχους τους

προμηθευτές και άλλους εμπλεκόμενους για να περιγράψει την

απαραίτητη λειτουργικότητα του ΗΦΥ

EHR-S Functional Model Standard Έχει δημιουργηθεί από την αρχή με διεθνή χαρακτηριστικά

Χαρακτηρίζεται από ευελιξία για να διαφοροποιούνται οι

υλοποιήσεις

Είναι εναρμονισμένο με laquoπαρόμοιεςraquo προσπάθειες στο

χώρο της υγείας όπως Committee eacute Europeacuteen de Normalisation (CEN 13606)

Institute Of Medicine

openEHR

ISOTC 215 International Standards Organization

Technical Specification 18308

ASTM E31

Περιέχει ~ 160 Λειτουργίες και ~1000 κριτήρια συμόρφωσης

Διαθέσιμο στο διαδίκτυο httpwwwhl7orgehr

Άξονες Βασικών Λειτουργιών EHR-S FM

Source HL7 EHR-S FM Overview Chapter

Άμεση Φροντίδα

Υποστηρικτικές Λειτουργίες

Πληροφοριακές Υποδομές

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 Standards Types

Healthcare-related datainformationrouting Standards Messaging Standards (V2x V3 FHIR)

Document Standards (CDA)

Healthcare-related Functional Standards (EHR-S FM)

Other Standards (CCOW Vocabulary Security

Healthcare Devices etc)

HL7 Messaging Standards

HL7 v2x

ADT lt-gt LIS

LIS

LIS

ADT

ADT

ORM - gt

ORR - gt

ACK - gt

ORU - gt

LIS message sample v2x

EHR-S Functional Model Standard

Ένα πολύ σημαντικό βήμα για να οριστεί και πιστοποιηθεί ένα

σύστημα ΗΦΥ (EHR)

Το EHR-S FM αναπαριστά ένα υπερσύνολο από λειτουργίες για ένα

σύστημα ΗΦΥ (EHR)

Περιγράφει σημαντικά χαρακτηριστικά και λειτουργίες που θα

πρέπει να περιέχονται σε ένα σύστημα ΗΦΥ

Παραθέτει μια λίστα από λειτουργίες στις οποίες το κάθε κριτήριο

χαρακτηρίζεται σαν laquoSHALLraquo laquoSHOULDraquo ή laquoMAYraquo

Δημιουργεί μια κοινή πλατφόρμα για τους παρόχους τους

προμηθευτές και άλλους εμπλεκόμενους για να περιγράψει την

απαραίτητη λειτουργικότητα του ΗΦΥ

EHR-S Functional Model Standard Έχει δημιουργηθεί από την αρχή με διεθνή χαρακτηριστικά

Χαρακτηρίζεται από ευελιξία για να διαφοροποιούνται οι

υλοποιήσεις

Είναι εναρμονισμένο με laquoπαρόμοιεςraquo προσπάθειες στο

χώρο της υγείας όπως Committee eacute Europeacuteen de Normalisation (CEN 13606)

Institute Of Medicine

openEHR

ISOTC 215 International Standards Organization

Technical Specification 18308

ASTM E31

Περιέχει ~ 160 Λειτουργίες και ~1000 κριτήρια συμόρφωσης

Διαθέσιμο στο διαδίκτυο httpwwwhl7orgehr

Άξονες Βασικών Λειτουργιών EHR-S FM

Source HL7 EHR-S FM Overview Chapter

Άμεση Φροντίδα

Υποστηρικτικές Λειτουργίες

Πληροφοριακές Υποδομές

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 Messaging Standards

HL7 v2x

ADT lt-gt LIS

LIS

LIS

ADT

ADT

ORM - gt

ORR - gt

ACK - gt

ORU - gt

LIS message sample v2x

EHR-S Functional Model Standard

Ένα πολύ σημαντικό βήμα για να οριστεί και πιστοποιηθεί ένα

σύστημα ΗΦΥ (EHR)

Το EHR-S FM αναπαριστά ένα υπερσύνολο από λειτουργίες για ένα

σύστημα ΗΦΥ (EHR)

Περιγράφει σημαντικά χαρακτηριστικά και λειτουργίες που θα

πρέπει να περιέχονται σε ένα σύστημα ΗΦΥ

Παραθέτει μια λίστα από λειτουργίες στις οποίες το κάθε κριτήριο

χαρακτηρίζεται σαν laquoSHALLraquo laquoSHOULDraquo ή laquoMAYraquo

Δημιουργεί μια κοινή πλατφόρμα για τους παρόχους τους

προμηθευτές και άλλους εμπλεκόμενους για να περιγράψει την

απαραίτητη λειτουργικότητα του ΗΦΥ

EHR-S Functional Model Standard Έχει δημιουργηθεί από την αρχή με διεθνή χαρακτηριστικά

Χαρακτηρίζεται από ευελιξία για να διαφοροποιούνται οι

υλοποιήσεις

Είναι εναρμονισμένο με laquoπαρόμοιεςraquo προσπάθειες στο

χώρο της υγείας όπως Committee eacute Europeacuteen de Normalisation (CEN 13606)

Institute Of Medicine

openEHR

ISOTC 215 International Standards Organization

Technical Specification 18308

ASTM E31

Περιέχει ~ 160 Λειτουργίες και ~1000 κριτήρια συμόρφωσης

Διαθέσιμο στο διαδίκτυο httpwwwhl7orgehr

Άξονες Βασικών Λειτουργιών EHR-S FM

Source HL7 EHR-S FM Overview Chapter

Άμεση Φροντίδα

Υποστηρικτικές Λειτουργίες

Πληροφοριακές Υποδομές

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 v2x

ADT lt-gt LIS

LIS

LIS

ADT

ADT

ORM - gt

ORR - gt

ACK - gt

ORU - gt

LIS message sample v2x

EHR-S Functional Model Standard

Ένα πολύ σημαντικό βήμα για να οριστεί και πιστοποιηθεί ένα

σύστημα ΗΦΥ (EHR)

Το EHR-S FM αναπαριστά ένα υπερσύνολο από λειτουργίες για ένα

σύστημα ΗΦΥ (EHR)

Περιγράφει σημαντικά χαρακτηριστικά και λειτουργίες που θα

πρέπει να περιέχονται σε ένα σύστημα ΗΦΥ

Παραθέτει μια λίστα από λειτουργίες στις οποίες το κάθε κριτήριο

χαρακτηρίζεται σαν laquoSHALLraquo laquoSHOULDraquo ή laquoMAYraquo

Δημιουργεί μια κοινή πλατφόρμα για τους παρόχους τους

προμηθευτές και άλλους εμπλεκόμενους για να περιγράψει την

απαραίτητη λειτουργικότητα του ΗΦΥ

EHR-S Functional Model Standard Έχει δημιουργηθεί από την αρχή με διεθνή χαρακτηριστικά

Χαρακτηρίζεται από ευελιξία για να διαφοροποιούνται οι

υλοποιήσεις

Είναι εναρμονισμένο με laquoπαρόμοιεςraquo προσπάθειες στο

χώρο της υγείας όπως Committee eacute Europeacuteen de Normalisation (CEN 13606)

Institute Of Medicine

openEHR

ISOTC 215 International Standards Organization

Technical Specification 18308

ASTM E31

Περιέχει ~ 160 Λειτουργίες και ~1000 κριτήρια συμόρφωσης

Διαθέσιμο στο διαδίκτυο httpwwwhl7orgehr

Άξονες Βασικών Λειτουργιών EHR-S FM

Source HL7 EHR-S FM Overview Chapter

Άμεση Φροντίδα

Υποστηρικτικές Λειτουργίες

Πληροφοριακές Υποδομές

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

LIS message sample v2x

EHR-S Functional Model Standard

Ένα πολύ σημαντικό βήμα για να οριστεί και πιστοποιηθεί ένα

σύστημα ΗΦΥ (EHR)

Το EHR-S FM αναπαριστά ένα υπερσύνολο από λειτουργίες για ένα

σύστημα ΗΦΥ (EHR)

Περιγράφει σημαντικά χαρακτηριστικά και λειτουργίες που θα

πρέπει να περιέχονται σε ένα σύστημα ΗΦΥ

Παραθέτει μια λίστα από λειτουργίες στις οποίες το κάθε κριτήριο

χαρακτηρίζεται σαν laquoSHALLraquo laquoSHOULDraquo ή laquoMAYraquo

Δημιουργεί μια κοινή πλατφόρμα για τους παρόχους τους

προμηθευτές και άλλους εμπλεκόμενους για να περιγράψει την

απαραίτητη λειτουργικότητα του ΗΦΥ

EHR-S Functional Model Standard Έχει δημιουργηθεί από την αρχή με διεθνή χαρακτηριστικά

Χαρακτηρίζεται από ευελιξία για να διαφοροποιούνται οι

υλοποιήσεις

Είναι εναρμονισμένο με laquoπαρόμοιεςraquo προσπάθειες στο

χώρο της υγείας όπως Committee eacute Europeacuteen de Normalisation (CEN 13606)

Institute Of Medicine

openEHR

ISOTC 215 International Standards Organization

Technical Specification 18308

ASTM E31

Περιέχει ~ 160 Λειτουργίες και ~1000 κριτήρια συμόρφωσης

Διαθέσιμο στο διαδίκτυο httpwwwhl7orgehr

Άξονες Βασικών Λειτουργιών EHR-S FM

Source HL7 EHR-S FM Overview Chapter

Άμεση Φροντίδα

Υποστηρικτικές Λειτουργίες

Πληροφοριακές Υποδομές

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

EHR-S Functional Model Standard

Ένα πολύ σημαντικό βήμα για να οριστεί και πιστοποιηθεί ένα

σύστημα ΗΦΥ (EHR)

Το EHR-S FM αναπαριστά ένα υπερσύνολο από λειτουργίες για ένα

σύστημα ΗΦΥ (EHR)

Περιγράφει σημαντικά χαρακτηριστικά και λειτουργίες που θα

πρέπει να περιέχονται σε ένα σύστημα ΗΦΥ

Παραθέτει μια λίστα από λειτουργίες στις οποίες το κάθε κριτήριο

χαρακτηρίζεται σαν laquoSHALLraquo laquoSHOULDraquo ή laquoMAYraquo

Δημιουργεί μια κοινή πλατφόρμα για τους παρόχους τους

προμηθευτές και άλλους εμπλεκόμενους για να περιγράψει την

απαραίτητη λειτουργικότητα του ΗΦΥ

EHR-S Functional Model Standard Έχει δημιουργηθεί από την αρχή με διεθνή χαρακτηριστικά

Χαρακτηρίζεται από ευελιξία για να διαφοροποιούνται οι

υλοποιήσεις

Είναι εναρμονισμένο με laquoπαρόμοιεςraquo προσπάθειες στο

χώρο της υγείας όπως Committee eacute Europeacuteen de Normalisation (CEN 13606)

Institute Of Medicine

openEHR

ISOTC 215 International Standards Organization

Technical Specification 18308

ASTM E31

Περιέχει ~ 160 Λειτουργίες και ~1000 κριτήρια συμόρφωσης

Διαθέσιμο στο διαδίκτυο httpwwwhl7orgehr

Άξονες Βασικών Λειτουργιών EHR-S FM

Source HL7 EHR-S FM Overview Chapter

Άμεση Φροντίδα

Υποστηρικτικές Λειτουργίες

Πληροφοριακές Υποδομές

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

EHR-S Functional Model Standard Έχει δημιουργηθεί από την αρχή με διεθνή χαρακτηριστικά

Χαρακτηρίζεται από ευελιξία για να διαφοροποιούνται οι

υλοποιήσεις

Είναι εναρμονισμένο με laquoπαρόμοιεςraquo προσπάθειες στο

χώρο της υγείας όπως Committee eacute Europeacuteen de Normalisation (CEN 13606)

Institute Of Medicine

openEHR

ISOTC 215 International Standards Organization

Technical Specification 18308

ASTM E31

Περιέχει ~ 160 Λειτουργίες και ~1000 κριτήρια συμόρφωσης

Διαθέσιμο στο διαδίκτυο httpwwwhl7orgehr

Άξονες Βασικών Λειτουργιών EHR-S FM

Source HL7 EHR-S FM Overview Chapter

Άμεση Φροντίδα

Υποστηρικτικές Λειτουργίες

Πληροφοριακές Υποδομές

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Άξονες Βασικών Λειτουργιών EHR-S FM

Source HL7 EHR-S FM Overview Chapter

Άμεση Φροντίδα

Υποστηρικτικές Λειτουργίες

Πληροφοριακές Υποδομές

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

EHR-S FM Παράδειγμα-κριτήρια συμμόρφωσης

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 v3 RIM

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 v3 RIM

The HL7 Reference Information Model (RIM) is a static model of

health and health care information

Combined consensus view of information from the perspective of

the HL7

Content of all HL7 version 30 protocol specification standards is

drawn

The RIM is modeled using the modeling syntax defined by UML

UML is a graphical language for visualizing specifying

constructing and documenting the artifacts of a software-intensive

system

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 RIM ndash Domain Model (HL7 ndashDF) RIM

(Static Model)

D-MIMDIM

Domain Model

R-MIMSIM

Serializable Model

ITS

Domains

(Scheduling

Domain

Pharmacy etc)

Specific categories

of interactions

(Inpatient admission)

CMETS

Models to

Messages

Documents

Implementation Technology

Specification

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 v3 RIM ndash Abstract Data Model

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 v3 RIM ndash Core Classes

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 v3 RIM ndash Back Bone Classes

Living Subject

Place

Organization

Material

Patient

Access

Employee

Licensed Entity

Managed

Participation

Observation

Encounter

Procedure

Substance

Adm

Financial

Transaction

Invoice

Control Act

helliphelliphellip

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 v3 RIM ndash Data Type Diagram

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

null Flavor hellip a special datatype case

NullFlavor does not mean ldquonullrdquo behaves like

it in many ways

Every data type (including properties) implicitly

carry information about how or why they are

incomplete or an improper value

Every data type may carry other information

even when null

Implementers must always consider null value

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

nullFlavor Types

code Name

NI no information

OTH Other

NINF negative infinity

PINF positive infinity

UNK Unknown

ASKU asked but unknown

NAV temporarily unavailable

NASK not asked

TRC Trace

MSK masked

NA not applicable

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 v3 RIM ndash Vocabulary Specifications

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document Architecture CDA

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document Architecture CDA

ANSIHL7 CDAreg Release 2

Περιγράφει την δομή και την οντότητες ενός

laquoΚλινικού Έγγραφουraquo (Clinical Document)

Αποτελεί προδιαγραφές για την ανταλλαγή

εγγράφων με τη χρήση τεχνολογιών όπως XML

HL7 Reference Information Model (RIM)

Version 3 methodology

Ιατρικές Κωδικοποιήσεις (SNOMED ICD localhellip)

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document Architecture CDA

Παραδείγματα CDA είναι Σύνοψη Εξιτηρίου για ασθενή

Παραπομπή ασθενή

Ιατρικές σημειώσεις laquoπροόδουraquo ασθενή

Έκθεση για τη δημόσια υγεία

Συνταγογράφηση ασθενή

Αναγγελία αιμοκάθαρσης ασθενή

Μπορεί να διαβαστεί από άνθρωπο

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document Architecture CDA

To CDA βασίζεται στο HL7 RIM και κάνει

χρήση των HL7 V3 Data Types

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA - Sample

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA History

1997 ndash HL7 SGML SIG begins work on the Patient Record Architecture

1998 ndash Patient Record Architecture draft

1999 ndash CDA Release 10 Approved by HL7 Membership

2000 ndash CDA Release 10 adopted as an American National Standard

2000 ndash HL7 XML SIG becomes Structured Documents Technical Committee

2005 ndash Clinical Document Architecture Release 2 Adopted

2006 ndash Care Record Summary Implementation Guide

2007 ndash Continuity of Care Document Implementation Guide

2008 ndash Recognition of HL7 CDA by the Secretary of HHS

2008 ndash Submission of CDA to ISO TC-215

2009 ndash ISO TC-215 Approves CDA as an ISO Standard

2010 ndash CDA reaffirmed by HL7 and ANSI as an American National Standard

2011 ndash Consolidated CDA Implementation Guide

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA in Details

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA Characteristics

Basic (CDA R2 21) Persistence

Stewardship (administration)

Potential for Authentication

Wholeness

Human readability

Context

Additional Render arbitrary documents

Additional information for computation

Flexibility to support different document types

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA is based on XML

XML is Extensible Markup Language (wwww3corg)

In XML structure amp format are conveyed by markup

which is embedded into the information

With a few simple tags and controlled vocabulary

XML can describe anything

XML alone isnrsquot enough the tags need to be defined

ltorderNumgt HL7 order placed

ltorderNumgt CDISC visit sequence

CDA tags are defined by the HL7 Reference Information

Model (RIM) and use standard controlled vocabulary

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Structure of a CDA document

Header Structured and Coded

Body structured with coded sections

Salutation

ProblemSubjective

History

PhysicalObjective

Diagnoses

Plan

helliphellip

Admit diagnoses

Intermediate diagnoses

Discharge diagnoses

Document context

Clinical information

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Structure of a CDA document Header

Body

Clinical Document

Body Entries (Clinical Statements)

Provider

Patient

Body Structures

Observation Procedure Encounter Medication

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Structure of a CDA document bull Header

(structured and coded)

bull Body (structured content with coded sections)

bull ProblemSubjective bull History

bull Family History bull Past Medical History

bull PhysicalObjective bull Diagnoses

bull Admit diagnoses bull Intermediate diagnoses bull Discharge diagnoses

ndash Coded ICD10

bull Therapy Plan bull helliphellip

ltClinicalDocumentgt

ltStructuredBodygt

ltSectiongt

lttextgt lttextgt

ltObservationgt

ltObservationgt

ltObservationgt

ltObservationgt

ltSectiongt

ltStructuredBodygt

ltClinicalDocumentgt

D

O

C

U

M

E

N

T

B

O

D

Y

S

E

C

T

I

O

N

E

N

T

R

I

E

S

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA Model

Header Body Structures Body Entries

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA Header

Document Identification (ID code title date hellip)

Confidentiality language authorisations

Authenticator(s) including legal authenticator

recipient(s) of the content

Author(s) Data enterer

Patient

Informants Content Producer

Related Document(s)

Service Event(s) Participant(s) Encounter

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document id

document unique identification

root amp extension

OID

Code

what type of document

using LOINC Codes

describe content

ltid root=21684011138833193799623252 extension=9e1ed519gt

lt-- Loinc Code for Document Nephrology Referral note --gt

ltcode code=57144-8 codeSystem=216840111388361 codeSystemName=LOINC displayName=Nephrology

Referral notegt

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document - Parties

recordTarget Patient

author who has written the document

custodian responsible organization

informationRecipient intended receivers (as

known at the time of creation of the document)

legalAuthenticator who has signed this

document

authenticator other signing persons

dataEnterer secretary

participant other assigned person

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document ndash Record Target - Patient id

unique id

lt-- Foreigner Social Security TYP Indicator - Τύπος Πιστοποιητικού Ασφάλισης Πολίτη ΕΕ -εκτός Ελλάδας(1= EKAA

2=ΠΠΑ) --gt

ltid extension=1 root=216840111388331937996232513gt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document ndash Record Target - Patient ltrecordTarget typeCode=RCT contextControlCode=OPgt

lt-- Patient Role - Default PAT --gt

ltpatientRole classCode=PATgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Address Details - Στοιχεία Διεύθυνσης --gt

ltaddr use=H PSTgt

lt-- Οδος --gt

ltstreetAddressLinegtΛΑΥΡΙΟΥltstreetAddressLinegt

lt-- Αριθμός --gt

ltstreetAddressLinegt11ltstreetAddressLinegt

lt-- ΤΚ --gt

ltpostalCodegt15662ltpostalCodegt

lt-- Πόλη --gt

ltcitygtΑΘΗΝΑltcitygt

lt-- Χώρα --gt

ltcountrygtGREECEltcountrygt

ltaddrgt

lt-- Αριθμός Τηλεφώνου use=H - Αριθμός Τηλεφώνου-Κινητό use=MC - email use=HP --gt

lt-- Αριθμός Τηλεφώνου lttelecom use=H value=tel55354257gt --gt

lt-- Αριθμός Τηλεφώνου-Κινητό lttelecom use=MC value=tel55354257gt --gt

lt-- email lttelecom use=HP value=mailtonameanydomaingt --gt

lttelecom use=H value=tel55354257gt

lttelecom use=MC value=tel55354257gt

lt-- Patient Name Details - Στοιχεία Ονόματος ΑσθενήΕξεταζόμενου --gt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ltpatientRolegt

ltrecordTargetgt

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document ndashPatient ltpatient classCode=PSN determinerCode=INSTANCEgt

ltnamegt

lt-- Όνομα --gt

ltgivengtΝΙΚΟΣltgivengt

lt-- Όνομα Πατέρα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

lt-- Φύλο - Values FFemale MMale UUndifferentiated --gt

ltadministrativeGenderCode code=M codeSystem=216840111388351 displayName=Malegt

lt-- Ημερομηνία Γέννησης --gt

ltbirthTime value=19620219gt

lt-- Στοιχεία Έμμεσα ασφαλισμένου --gt

ltguardian classCode=GUARDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

lt-- Fully insured coverage sponsor --gt

ltcode code=FULLINS codeSystem=21684011138835111 codeSystemName=RoleCodegt

ltguardianPersongt

lt-- Όνομα του Αμεσα Ασφαλισμένου--gt

ltnamegt

lt-- Όνομα --gt

ltgivengtΓΕΩΡΓΙΟΣltgivengt

lt-- Επίθετο --gt

ltfamilygtΠΑΠΠΑΣltfamilygt

ltnamegt

ltguardianPersongt

ltguardiangt

ltpatientgt

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document ndash Author

lt-- Doctor responsible for the Document - Author of this document --gt

ltauthor typeCode=AUTgt

ltfunctionCode code=221 codeSystem=2168401113883225601102 displayName=Doctor

codeSystemName=epSOSHealthcareProfessionalRolesgt

lttime nullFlavor=NAgt

ltassignedAuthor classCode=ASSIGNEDgt

lt-- ΑΜΚΑ ή SSN --gt

ltid extension=1234567890 root=21684011138833193799623257gt

ltassignedPerson classCode=PSN determinerCode=INSTANCEgt

ltnamegt

ltgivengtΚΩΣΤΑΣltgivengt

ltfamilygtΦΩΤΙΟΥltfamilygt

ltnamegt

ltassignedPersongt

ltassignedAuthorgt

ltauthorgt

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document ndash encompassingEncounter

ltcomponentOfgt

ltencompassingEncountergt

lt-- Id Επίσκεψης --gt

lttemplateId root=180 extension=3479 gt

ltlocationgt

lthealthCareFacilitygt

lt-- Ιd Μονάδας Συνταγογράφησης User_Unit_Id --gt

lttemplateId root=1801 extension=101002gt

ltlocationgt

lt-- Όνομα Μονάδας Συνταγογράφησης --gt

ltnamegtMEGAltnamegt

ltlocationgt

lthealthCareFacilitygt

ltlocationgt

ltencompassingEncountergt

ltcomponentOfgt

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document ndash Body - Model

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document ndash NonXMLBody

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=applicationpdf representation=B64gt REPLACE_ME WITH B64 ENCODED PDF lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=imagejpggt

ltreference value=labnonxmljpggt

lttextgt

ltnonXMLBodygt

ltcomponentgt

ltcomponent typeCode=COMPgt

ltnonXMLBodygt

lttext mediaType=textplaingt Hello this is a test record lttextgt

lttextgt

ltnonXMLBodygt

ltcomponentgt

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document ndash Component Model

Iterative definition

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Section Levels

CDA Release 2

CDA Level 1

Non constrained CDA specification

CDA Level 2

CDA specification with section level templates

CDA Level 3

CDA specification with entry level and optionally

section-level templates

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

ltSectiongt

ltcode code=10153-2 codeSystem=LOINCldquogt

Past Medical History

ltcodegt

lttextgtltlistgt

ltitemgtltcontentgtAsthmaltcontentgtltitemgt

ltitemgtltcontentgtHypertensionltcontentgtltitemgt

ltitemgtltcontent ID=ldquoa3rdquogtOsteoarthritis right kneeltcontentgtltitemgt

ltlistgtlttextgt

ltcomponent1gt

ltcontextConductionInd value=TRUEgt

ltObservation classCode=ldquoCONDrdquogt

ltcode code=rdquoG-1001rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquoPrior dxrdquogt

ltvalue code=rdquoD1-201A8rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoOsteoarthritisrdquogt

ltoriginalTextgtltreference value=rdquoa3rdquogtltoriginalTextgt

ltvaluegt

lttargetSiteCode code=rdquoT-15720rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquoKnee jointrdquogt

ltqualifiergt

ltname code=rdquoG-C220rdquo codeSystem=rdquoSNOMEDrdquo

displayName=rdquowith lateralityrdquogt

ltvalue code=rdquoG-A100rdquo codeSystem=rdquoSNOMEDrdquo displayName=rdquorightrdquogt

ltqualifiergt

ltoriginalTextgtltreference value=rdquoa4rdquogtltoriginalTextgt

lttargetSiteCodegt

ltObservationgt

ltcomponent1gt

ltSectiongt

Section Levels 123

human readable

machine processible

Level 2

Level 1

Level 3

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document ndash Sections ndash Level 1

Human interoperability

ltcomponentgt

ltsectiongt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management He was

hospitalized twice last year and already twice this year He has not been able to be weaned off

steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document ndash Sections ndash Level 2 Section Code

Using LOINC

Coding strength CWE (Coded with Exceptions)

ltcomponentgt

ltsectiongt

ltcode code=10164-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtHistory of Present Illnesslttitlegt

lttextgt

Henry Levin the 7th is a 67 year old male referred for further asthma management

He was hospitalized twice last year and already twice this year He has not been able to be weaned

off steroids for the past several months

lttextgt

ltsectiongt

ltcomponentgt

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Clinical Document ndash Sections ndash Level 3

Machine processible ltcomponentgt

ltsectiongt

ltcode code=10153-2 codeSystem=216840111388361 codeSystemName=LOINCgt

lttitlegtPast Medical Historylttitlegt

lttextgt

ltlistgt

ltitemgt

ltcontent ID=a1gtAsthmaltcontentgt

ltitemgt

ltlistgt

lttextgt

ltentry typeCode = ldquoCOMPrdquogt

ltObservation classCode=CONDgt

ltcode code=39154008 codeSystem=2168401113883696 codeSystemName=SNOMED CT displayName=clinical

diagnosisgt

lteffectiveTime value=1950gt

ltvalue xsitype=CD code=195967001 codeSystem=2168401113883696 codeSystemName=SNOMED CT

displayName=Asthmagt

ltoriginalTextgt

ltreference value=a1gt

ltoriginalTextgt

ltvaluegt

ltObservationgt

ltentrygt

ltsectiongt

ltcomponentgt

Referencing Entries

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

entryRelationship types

COMP (component)

narrative is the original authenticated content

DRIV (derived from)

narrative is fully derived from CDA Entries

EMR (Database) Narrative text CDA entry

EMR (Database) CDA entry Narrative text

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA Incremental Semantic Interoperability

Standard HL7 metadata

Simple XML for point of care human readability

RIM semantics for reusable computability (ldquosemantic interoperabilityrdquo)

Source Alschuler_CCD_May09

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA vs Messages

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Relationship to HL7 messages

CDA complements HL7 messaging specs

A CDA document is a defined and complete information

object that can exist outside of a messaging context

A CDA document can be a MIME-encoded payload

within an HL7 message (HL7 v2x)

CDA documents do not need an HL7 message to

provide context

v3 messaging support CDA transport

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

more hellip Documents vs Messaging

HL7 itself hasnrsquot created any recommendation - how to

use it

Messages are generally used to support an ongoing

process in a real-time

Documents are about persisting snapshots as

understood at a particular time

Documents are passiveldquo

CDA is easier than v3 messaging

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA Transport

xslt transform and then fax email etchellip

HL7 messaging (v2x v3)

Custom Web Services (SOAP XML-RPC REST)

IHE XDS

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Security Confidentiality and Data Integrity

Application systems sending and receiving CDA documents are

responsible for meeting all legal requirements for document

authentication confidentiality and retention

For communications over public media cryptographic techniques

for sourcerecipient authentication and secure transport of

encapsulated documents may be required and should be

addressed with commercially available tools outside the scope of

this standard

The CDA does provide confidentiality status information to aid

application systems in managing access to sensitive data

Confidentiality status may apply to the entire document or to

specified segments of the document

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA Templates

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA Templates

Defines additional syntax rules that constrain the overall CDA

syntax and semantics for a specific kind of CDA document (or

portion of a CDA document)

Can be a document template defines overall rules for an entire CDA document

more specific header template

section template

entry template

Templates form a hierarchy Document templates indicate which header templates and section templates should be used section

templates can reference additional nested section templates and entry templates and entry templates

can contain other entry templates

Templates can be mixed and matched and re-used For example the same entry template can be used inside other entry templates or section templates

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA Templates

Model-driven computable objects that can be stored in a database

that functions as a CDA template library

Such template libraries support both standards development and

implementation

Example Art-Deacutecor

Source Lantana Consulting Group Templated CDA May 2011

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA Template Manager

MDHT Model-Driven Health Tools (MDHT) for CDA

mainly in US

generates validation source code

httpwwwcdatoolsorg

Art-Deacutecor mainly used in some European countries

schematron based validation

httpwwwart-decororg

Source Lantana Consulting Group Templated CDA May 2011

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA implementation guides

Consolidated CDA ldquoC-CDArdquo

Doesnrsquot necessarily mean itrsquos a good match for the specific requirements

IHE Medical Summary CDA Implementation guide

defined in the IHE PCC profile

European epSOS implementation guide

A lot of templates are reusable

German Discharge Letter implementation guide

A lot of others can be found helliphellip

Source Lantana Consulting Group Templated CDA May 2011

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA vs C-CDA

C-CDA defines a set of CDA documents

The HL7 Consolidated CDA is an implementation guide which

specifies a library of templates and describe their use for a set of

specific document types

CDA the schema for those documents

The HL7 Clinical Document Architecture (CDA) is a document

markup standard that specifies the structure and semantics of

clinical documents for the purpose of exchange

Source Lantana Consulting Group Templated CDA May 2011

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 C-CDA Implementation Guide

Document Organization

Introduction

General Header Template

Document-Level Templates

Section-Level Templates

Entry-Level Templates

Appendix

Template IDs Code Systems Value Sets

Extensions hellip

Source Lantana Consulting Group Templated CDA May 2011

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA Validation

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA Validation

Validates against the published XML Schema

XML Schema based validation tool

Validates against the abstract CDA model specification

Use a MIF - Model Interchange Format (specification of the

abstract model) based validation tool includes conformance

and vocabulary validation

Validates against requirements templates as specified

in implementation guides

Mostly a XML Schematron based validation tool could be

MIFOCL based

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA Validation - Schematron

A way to test XML documents

Rules-based validation language

XML schema language

Others are W3C XML Schema RelaxNG etc

ISO standard

Schema is a collection of patterns

Patterns contain one or more rules with a context

Rules assert that a test has passed

Failures may issue diagnostics

The output of schematron validation is an XML report on the

validation status of the instance

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA Validation - Example Schematron

ltrule context=hl7typeIdgt

ltassert role=errorldquo

test=extension=POCD_HD000040gt

ClinicalDocumenttypeId (216840111388324610353)

extension SHALL have value POCD_HD000040 static ltassertgt

ltassert role=error test=root=216840111388313gt

ClinicalDocumenttypeId (216840111388324610353)

root SHALL have value 216840111388313 static ltassertgt

ltrulegt

Source V3 Software Implementation Reneacute Spronk

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA Validation - Tools

Schematron

httpwwwschematroncom

httpxmlasccnetresourceschematronschematronhtml

National Institute of Standards and Technology (NIST)

httpcda-validationnistgovcda-validationvalidationhtml

IHE Gazzele

httpgazelleihenetEVSClientcdavalidatorseam

Art Deacutecor

httpsart-decororgmediawikiindexphpMain_Page

Source V3 Software Implementation Reneacute Spronk

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA Development

Art-Deacutecor

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Medical Ανάλυση σεναρίου χρήσης (use case)

Ανάλυση διαλειτουργικότητας (transactions)

Προσδιορισμός δεδομένων που χρησιμοποιούνται

(data sets)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash Terminology Προσδιορισμός προκαθορισμένων τιμών

Προσδιορισμός Συστημάτων κωδικοποίησης (πχ

ICD10 κλπ)

Προσδιορισμός στόχων κωδικοποίησης

(ανάλυση στατιστική κλπ)

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Ανάγκες ανάπτυξης CDA - Μεθοδολογία

Problem Domain ndash ICT HL7v3

Reference Information Model

XML serialization

XML Schema

CDA (part text part structured data)

RIM (Reference Information Model) Backbone

OIDs

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

DECOR overview

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

DECOR

dataset

project

name

scenario

copyright version info

description authors

issues

value sets

identi-

fications

rules

concept group item

use case

transaction actor

code systems terminology

systems

validation

conditions constraints

OID

status assignment

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

DECOR and ART technology

A DECOR file is an XML file

methodology developed by dr Kai U Heitmann

basis for transformations to other HTML XML

fine basis for schema(tron)

has its own schema (DECORxsd)

ART is tooling to make DECOR files

tooling developed by Gerrit Boers

ART is made with XQuery XForms

open source products eXist Orbeon

ART and DECOR are open source (GPL LGPL)

team Kai Gerrit Alexander Henket Maarten Ligtvoet Marc

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

DECOR amp ART stakeholders

Healthcare

Terminologists

ICT Architects

HL7v3

modellers

IT vendors

Testing

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

DECOR Output

Care Provider view

Technical Documentation

XML CSV resources for implementers

Schematron UI-Generation (xml for application)

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

What Next hellip R3

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

CDA R3

First option minimal upgrade that retains backwards

compatibility (like R21)

Second option underlying format for the next release of CDA will

be based on the technical vehicle of FHIR rather than the technical

vehicle of the RIM base

Same goals with CDA R2 by a different technical route

Now a lot of design activity has moved to CDA R2 anyway

(principally CCDA and EPSOS)

In future CDA implementation guides will be based on templates

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR

F H I R

Fast Healthcare Interoperability Resources

reg

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ldquowhyrdquo

Ανάγκη για ldquoFresh Lookrdquo

Προβλήματα με τα υπάρχοντα πρότυπα

Real time Access API (think mobile)

Νέα εργαλεία ανάπτυξης ndash νέες τεχνολογίες

Νέες ανάγκες ldquopatient engagementrdquo - gt Mobile API -gt Real-time Access

Smart ApplicationsSystems -gt API Architecture

Μείωση του κόστους

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR

Το πιο νέο πρότυπο με την μεγαλύτερη δυναμική

Αποτέλεσμα της προσπάθειας να υπερκεραστούν τα

υπάρχοντα προβλήματα HL7 V2 ndash Γενικότητα Προαιρετικότητα

HL7 V3 ndash Πολυπλοκότητα

Έμφαση σε αυτούς που υλοποιούν

Χρήση μοντέρνων τεχνολογιών

Πληροφορίες αναγνώσιμες από ανθρώπους

Καινούργια αρχιτεκτονική προσέγγιση (RESTful) σε σύγκριση

με το HL7v2 και το CDA ndash διαχείριση ανεξάρτητων πόρων

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR

Το μόνο πλήρως laquoανοικτόraquo και ελεύθερο πρότυπο

Open Source Project

Ανάπτυξη υποστηριζόμενη από ldquoConnectathonsrdquo

laquoΠοιο Εύκοληraquo διαλειτουργικότητα ndash Δεν χρειάζεται γνώση

του Domain

Έχει την πιο ευρεία υποστήριξη από όλα τα πρότυπα Software Industry

Health Care Providers

Interface Engines

Initiatives (IHE ONC)

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR History

~ 5 χρόνια ανάπτυξη

2012 ο Grahame Grieve το laquoμετέφερεraquo στο HL7

1ο Ballot ndash Μάιο 2013

1ο DSTU ndash Ιαν 2014 DSTU ldquogood enough to start play with itrdquo ndash πολύ κοντά στην τελική

μορφή

2ο DSTU ndash Σεπτ 2015 STU hellip

Normative ~ 1 year ()

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR Versions

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR

DSTU 1 υποστηρίζει 50 Resources

DSTU 2 υποστηρίζει 104 Resources

Στην τελική μορφή αναμένεται να υποστηρίζει ~ 150

Resources

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR in Details

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash Βασικά Δομικά Στοιχεία

Resources

References

Profiles

Μικρές Δομικές Μονάδες

(πόροι) χρήσιμες στην

ανταλλαγή δεδομένων

Διασύνδεση με

αναφορές μεταξύ των

δομικών στοιχείων

(πόροι)

Πως μπορεί να

χρησιμοποιηθεί

laquoεξειδίκευσηraquo

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Transport - Queries using HTTP

Restful Interface ndash Interactions read GET [base][type][id]

vread GET [base][type][id]_history[vid]

update PUT [base][type][id]

delete DELETE [base][type][id]

history GET [base][type][id]_history

create POST [base][type]

search GET [base][type] [parameters]

conformance GET [base]metadata | OPTIONS [base]

batchtransaction POST [base]

More at httpswwwhl7orgfhirhttphtml

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR REST Calls

Read GET httpfhirexamplecomPatient111

Vread GET httpfhirexamplecomPatient111_history2

Update PUT httpfhirexamplecomPatient

Conditional Updates PUT httpfhirexamplecomPatientidentifier=system7C00001

Delete DELETE httpfhirexamplecomPatient111

Create POST httpfhirexamplecomPatient

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR REST Calls

Search GET httpfhirexamplecomPatient

Search with parameters GET httpfhirexamplecomPatientfamily=SMITH

Search with parameters GET httpfhirexamplecomObservationbirthdate=gt=2011-01-02

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Responses XML - JSON ltEncounter xmlns=httphl7orgfhirgt

ltid value=f203gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130311gt

ltidentifiergt

ltstatus value=finishedgt

ltclass value=inpatientgt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=183807002gt

ltdisplay value=Inpatient stay for nine daysgt

ltcodinggt

lttypegt

ltprioritygt

lt-- High priority --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=394849002gt

ltdisplay value=High prioritygt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

helliphelliphelliphellip

resourceType Encounter

id f203

text

identifier [

use temp

value Encounter_Roel_20130311

]

status finished

class inpatient

_class

fhir_comments [

Encounter has finished

]

type [

fhir_comments [

Inpatient encounter for straphylococcus infection

]

coding [

system httpsnomedinfosct

code 183807002

display Inpatient stay for nine days

]

]

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Resource OperationOutcome

A collection of error warning or information messages that result

from a system action

Location Element - XPath

ltlocation value=fPatientfidentifier[2]flabelgt

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Cover the 80

Target is C-CDA

+ =

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR Resources

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash Resources (Πόροι)

Οι μικρότερες οριζόμενες μονάδες που συμμετέχουν στην ανταλλαγή

Αυτή την φορά έχουν οριστεί μόνο τα βασικά δεδομένα

Ενσωματωμένος μηχανισμός επεκτασιμότητας (8020 Rule)

Δυνατότητα χρήσης μόνο κειμένου

Περιορισμένη και απλοποιημένη χρήση Data Types

v2 =gt Segments | v3 =gt CMETs

Δεν αντικατοπτρίζει RIM modeling ISO datatype (variant)

Παράδειγμα Πρόσωπο (Person)

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash Κατηγορίες Resources

Identification resources ndash people places

Clinical resources ndash problems allergies medical date

Workflow resources ndash referral track processes

Infrastructure resources ndash binary images architectural

framework

Conformance resources ndash profiles interoperability

Financial resources - TBD

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash Resource UML

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash Patient Resource (15) ltPatient xmlns=httphl7orgfhirgt

ltid value=ldquo1234567890gt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt

lttablegt

lttbodygt

lttrgt

lttdgtNamelttdgt

lttdgtPeter James ltbgtChalmersltbgt (ampquotJimampquot) lttdgt

lttrgt

lttdgtIdlttdgt

lttdgtMRN 12345 (Acme Healthcare)lttdgt

lttbodygt

lttablegt

ltdivgt

lttextgt

lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

helliphelliphelliphelliphellip

Resource

Identification

Human readable

Summary

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash Patient Resource (25) lt-- MRN assigned by ACME healthcare on 6-May 2001 --gt

ltidentifiergt

ltuse value=usualgt

lttypegt

ltcodinggt

ltsystem value=httphl7orgfhirv20203gt

ltcode value=MRgt

ltcodinggt

lttypegt

ltsystem value=urnoid123614659521701gt

ltvalue value=12345gt

ltperiodgt

ltstart value=2001-05-06gt

ltperiodgt

ltassignergt

ltdisplay value=Acme Healthcaregt

ltassignergt

ltidentifiergt

ltactive value=truegt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient

Identification

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash Patient Resource (35) lt-- Peter James Chalmers but called Jim --gt

ltnamegt

ltuse value=officialgt

ltfamily value=Chalmersgt

ltgiven value=Petergt

ltgiven value=Jamesgt

ltnamegt

ltnamegt

ltuse value=usualgt

ltgiven value=Jimgt

ltnamegt

lttelecomgt

ltuse value=homegt

lt-- home communication details arent known --gt

lttelecomgt

lttelecomgt

ltsystem value=phonegt

ltvalue value=(03) 5555 6473gt

ltuse value=workgt

lttelecomgt

lt-- use FHIR code system for male female --gt

ltgender value=malegt

ltbirthDate value=1974-12-25gt

ltextension url=httphl7orgfhirStructureDefinitionpatient-birthTimegt

ltvalueDateTime value=1974-12-25T143545-0500gt

ltextensiongt

ltbirthDategt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash Patient Resource (45) ltdeceasedBoolean value=falsegt

ltaddressgt

ltuse value=homegt

lttype value=bothgt

ltline value=534 Erewhon Stgt

ltcity value=PleasantVillegt

ltdistrict value=Rainbowgt

ltstate value=Vicgt

ltpostalCode value=3999gt

ltperiodgt

ltstart value=1974-12-25gt

ltperiodgt

ltaddressgt

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Demographics

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash Patient Resource (55) ltcontactgt

ltrelationshipgt

ltcodinggt

ltsystem value=httphl7orgfhirpatient-contact-relationshipgt

ltcode value=partnergt

ltcodinggt

ltrelationshipgt

ltnamegt

ltfamily value=dugt

ltextension url=httphl7orgfhirStructureDefinitioniso21090-EN-qualifiergt

ltvalueCode value=VVgt

ltextensiongt

ltfamilygt

ltfamily value=Marcheacutegt

ltgiven value=Beacuteneacutedictegt

ltnamegt

lttelecomgt

ltsystem value=phonegt

ltvalue value=+33 (237) 998327gt

lttelecomgt

ltgender value=femalegt

ltperiodgt

ltstart value=2012gt

ltperiodgt

ltcontactgt

ltmanagingOrganizationgt

ltreference value=Organization1gt

ltmanagingOrganizationgt

ltPatientgt

Patient Contact

Managing Organization

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash Observation Resource (12) ltObservation xmlns=httphl7orgfhirgt

ltid value=examplegt

lttextgt

lttextgt

ltstatus value=finalgt

ltcategorygt

ltcodinggt

ltsystem value=httphl7orgfhirobservation-categorygt

ltcode value=vital-signsgt

ltdisplay value=Vital Signsgt

ltcodinggt

ltcategorygt

ltcodegt

lt-- LOINC - always recommended to have a LOINC code --gt

ltcodinggt

ltsystem value=httploincorggt

ltcode value=3141-9gt

ltdisplay value=Weight Measuredgt

ltcodinggt

lt-- SNOMED CT Codes - becoming more common --gt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=27113001gt

ltdisplay value=Body weightgt

ltcodinggt

ltcodegt

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash Observation Resource (22) ltsubjectgt

ltreference value=Patientexamplegt

ltsubjectgt

ltencountergt

ltreference value=Encounterexamplegt

ltencountergt

lt-- In FHIR units may be represented twice Once in the

agreed human representation and once in a coded form

Both is best since its not always possible to infer

one from the other in code

When a computable unit is provided UCUM (httpunitsofmeasureorg)

is always preferred but it doesnt provide notional units (such as

tablet) etc For these something else is required (eg SNOMED CT)

--gt

ltvalueQuantitygt

ltvalue value=185gt

ltunit value=lbsgt

ltsystem value=httpunitsofmeasureorggt

ltcode value=[lb_av]gt

ltvalueQuantitygt

ltObservationgt

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash Encounter Resource (12)

ltEncounter xmlns=httphl7orgfhirgt

ltid value=f201gt

lttextgt

lttextgt

ltidentifiergt

ltuse value=tempgt

ltvalue value=Encounter_Roel_20130404gt

ltidentifiergt

ltstatus value=finishedgt

lt-- Encounter has finished --gt

ltclass value=outpatientgt

lt-- Outpatient encounter for consultation --gt

lttypegt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=11429006gt

ltdisplay value=Consultationgt

ltcodinggt

lttypegt

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash Encounter Resource (22) ltprioritygt

ltcodinggt

ltsystem value=httpsnomedinfosctgt

ltcode value=17621005gt

ltdisplay value=Normalgt

ltcodinggt

ltprioritygt

ltpatientgt

ltreference value=Patientf201gt

ltdisplay value=Roelgt

ltpatientgt

ltparticipantgt

ltindividualgt

ltreference value=Practitionerf201gt

ltindividualgt

ltparticipantgt

ltreasongt

lttext value=The patient had fever peaks over the last couple of days He is worried

about these peaksgt

ltreasongt

ltserviceProvidergt

ltreference value=Organizationf201gt

ltserviceProvidergt

ltEncountergt

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash Consent Resource ltConsent xmlns=httphl7orgfhirgt

ltid value=consent-example-basicgt

lttextgt

ltstatus value=generatedgt

ltdiv xmlns=httpwwww3org1999xhtmlgt ltpgt Authorize Normal access for Treatment ltpgt ltdivgt

lttextgt

ltstatus value=activegt

ltdateTime value=2016-05-11gt

ltperiodgt

ltstart value=1964-01-01gt

ltend value=2016-01-01gt

ltperiodgt

ltpatientgt

ltreference value=Patientf001gt

ltdisplay value=P van de Heuvelgt

ltpatientgt

ltorganizationgt

ltreference value=OrganizationInfowaygt

ltdisplay value=Canada Infowaygt

ltorganizationgt

ltsourceAttachmentgt

lttitle value=The terms of the consent in lawyer speakgt

lt-- likely use url pointer to common text --gt

ltsourceAttachmentgt

lt-- this is plain out opt-out with no exceptions --gt

ltpolicy value=httpgoodhealthorgconsentpolicyopt-outgt

ltConsentgt

HL7 FHIR ndash Current Build

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR Documents

Very close to CDA

Collection of Resources

Document lt=gt CDA

Header

One Context

Signed - Authenticated

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR Messages

Similar to v2 - v3

Collection of Resources

Message lt=gt MSH

Not used often ndash special

proposes

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR References

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash References (Αναφορές)

Διασύνδεση μεταξύ ενός πόρου (resource) και ενός άλλου

Δημιουργείται ένα δίκτυο από πληροφορίες που αναπαριστούν

μέρος από έναν φάκελο υγείας

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR ndash References (Αναφορές)

Patient

Practitioner

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR Extensions - Profiles

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR ensure interoperability

Operations

lightweight operation framework that extends the

RESTful API

POST httpfhirsomeserverorgfhirPatient1$everything

Profiles

more specific resource definition

Conformance resources

conformance statement

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR extensions

v2 =gt Z segments

v3 =gt Foreign namespaces

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR - Resource Profile (Προφίλ)

Conformance profile Μια επίσημη περιγραφή για το πώς

χρησιμοποιείται το ldquoresourcerdquo στην συγκεκριμένο περιεχόμενο

Περιγραφεί τους περιορισμούς (constrains)

Περιγράφει τις επεκτάσεις (extensions)

Διασύνδεση με άλλα προφίλ resources για resources references

(σύνθεση)

Περιγράφει τις κωδικοποιήσεις που χρησιμοποιούνται

Είναι και το ίδιο resource

Messaging events ndash search operations

FHIR Conformant (publish Conformance instance)

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HL7 FHIR - Resource Profile (Προφίλ)

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR Security

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Security topics

Authentication ndash Ποιος χρήστης

Authorization ndash Τι πρέπει να βλέπει ο χρήστης

Client Identification ndash Ποιο σύστημα προσπελαύνει τα δεδομένα

Transport security ndash Πως μεταφέρονται τα δεδομένα

Provenance ndash Από πού ήρθε η πληροφορία

Audit ndash Ποιος άλλαξε τα δεδομένα και πότε

Αλλά δεν ορίζονται λειτουργίες security μόνο ldquosecurity protocols

suggestionsrdquo

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Security Communication (Transport)

Rest Operations

HTTP over TLS

Bidirectional encryption

Digital Certificates

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Open Standard ndash resources are available

Access Token

Authorization Server keeps passwords

Token valid for limited time (refresh)

Authorization Server validate System (client

key)

Different types of workflows

hellip OpenID Connect (on top)

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Authentication - Authorization (OAuth2)

Hay on FHIR Blog

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Permissions ndash ldquoScoperdquo

Hay on FHIR Blog

Specify access to what hellip

RO ndash RW etc

System or app VS User

SMART Scopes

httpdocssmarthealthitorgauthorizationscopes-and-

launch-context

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Audit ndash Tags - Labels

Hay on FHIR Blog

Meta property for resources Version ID

lastUpdated

Profile

Tag

Security tag ndash constraint on server and client

Security Labels Approve oparations (update read etchellip)

Level of resource returned

VIP

ldquoBreak the Glassrdquo

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Provenance

Hay on FHIR Blog

Provenance (resource) Tracks information about the activity that created a version of a

resource including the entities and agents involved in producing

a resource Tag Target (reference to version procedure etc)

Tag Entity

Tag Agent

Tag Activity

More at W3C Provenance specification

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Audit

Hay on FHIR Blog

Security event logging

Based on IHE-ATNA and DICOM

Not all but ldquobreak the glassrdquo

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR Implementation

- Development

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Open Source Implementations

De facto reference server httpfhirhealthintersectionscomau

Furore httpsgithubcomfurore-fhirspark

Univercity Health Network

FHIRBase httpsgithubcomfhirbasefhirbase

Smart Platforms httpsfhir-open-apismarthealthitorg

HAPI FHIR

httpsgithubcomjamesagnewhapi-fhir

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR Implementations Tools

FHIR Java Reference Client httpsgithubcomcnanjoFhirJavaReferenceClient

Hapi FHIR Java httpjamesagnewgithubiohapi-fhir

Furore NET open source tool httpsgithubcomewoutkramerfhir-net-api

Furore Forge (Profiling)

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

HAPI FHIR (Java)

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

IHE Mobile Access To Medical Data MHD

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Where is FHIRhellip hl7orgfhir

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR specifications

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR vs HL7v3 (CDA)

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR ndash CDA Comparison

CDA is not a core messaging protocol

HL7 v2 is a core messaging protocol

HL7 v3 is a core messaging protocol ndash CDA is part

Better compare between v2 and v3

But CDA adoption to popular use cases lead to this

comparison

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR vs V3 (CDA)

CDA

ModelerDomain Expert before ImplementerDeveloper

Want to do everything

Specification against implementable

CDA less cluttered - FHIR least cluttered

FHIR direct use of other standards (DICOM)

CDA only clinical () ndash FHIR other context

FHIR true reusability

CDA only documents ndash FHIR both (messaging and documents)

FHIR use JSON

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR vs V3 (CDA)

Templates vs resource profiling

Clinical Statement vs resources

expressed using a complex and extremely abstract model

Total RIM vs Partial RIM

Mappings between FHIR and CDA should be done at the template

level rather than the CDA specification itself

100 - everything from RIM vs 80

but FHIR was strong influenced by CDA

FHIR may replace C-CDA in the future

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Combine them ndash CDA on FHIR

Specifies how to implement CDA R2 with the FHIR Composition

resource

Scope of CDA on FHIR is the standardization of clinical documents

for exchange

Map CDA to FHIR (Header and basic sections and entries CCDA)

httpwikihl7orgindexphptitle=C-CDA_on_FHIR

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR vs CDA Trends

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR Hype

FHIR

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Standards Positioning

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

FHIR what to do

Read Documentation httpswwwhl7orgfhir

Use tools to implement

Use test servers to test it

Participate at httpschatfhirorg

Invent the next ldquomeaningful service for patientsrdquo

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr

Σας ευχαριστώ httpwwwhl7orggr

kyriakoyapollogr