Introduction to FHIR Lloyd McKenzie January 14, 2013
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This presentation
Can be downloaded here:
http://gforge.hl7.org/svn/fhir/trunk/presentations/20 13 01 T 13-01 Tutorials/Introduction t i l /I t d ti to t FHIR.pptx FHIR t
Is licensed for use under the Creative C Commons, specifically: ifi ll
Creative Commons Attribution 3.0 Unported License (Do with it as you wish, so long as you give credit)
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Who am I?
Name: Lloyd McKenzie Company: Gordon Point Informatics (GPi) Background:
Initial p participant p in FHIR core team Co-chair FHIR Management Group Co-chair HL7 Modeling g & Methodology gy Chair HL7 Canada Architecture & Infrastructure Heavily involved in HL7 and healthcare exchange for last 14 years (v2, v3, CDA, etc.)
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Who are you?
What’s your background with HL7?
What’s your role?
v2? v3? CDA? Brand new? Developer? Manager? Clinician? Other?
What’s the single most important thing for you to g y get out of today’s y course?
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Tutorial Objectives
You should:
Be able to explain what FHIR is to others in your organization i ti Know where FHIR fits in the broader healthcare landscape including other HL7 specifications landscape, Be equipped to help your organization determine if,, when,, where and how you y might g use FHIR Know how to approach the FHIR specification to find out what more you need to know
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WHAT IS FHIR?
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Answer: An instigator of b d puns bad
FHIR is the hottest thing since . . . This spec is spreading like . . . Committee X is really on FHIR Feel free to come up with your own
(but please, not here )
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The Need
Has been a need to share healthcare information electronically for a long time
HL7 v2 is over 25 years old
Increasing pressure to broaden scope of sharing
Across organizations, disciplines, even borders Mobile & cloud-based applications Faster – integration in days or weeks, not months or years
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The Need
Q: So what did HL7 have to offer in this space? A: Not much
V3 attempted to address some of these issues, but too slow and too hard CDA has had the most success, but both limited and still too hard
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Genesis of FHIR
HL7 undertook a “Fresh look”
Web search for success markers led to RESTf l based RESTful b d APIs API
What would healthcare exchange look like if we started t t d from f scratch t h using i modern d approaches? h ?
Exemplar: Highrise (https://github com/37signals/highrise api) (https://github.com/37signals/highrise-api)
Drafted a healthcare exchange API based on this approach
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The acronym
F – Fast (to design & to implement)
H – Health
That’s why we’re here
I – Interoperable
Relative – No technology can make integration as f t as we’d fast ’d lik like
Ditto
R – Resources
Building blocks – more on these to follow
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FHIR PRINCIPLES
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FHIR Manifesto
Focus on Implementers Target support for common scenarios Leverage cross-industry web technologies Require human readability as base level of interoperability Make content freely available Support multiple paradigms & architectures D Demonstrate t t best b t practice ti governance
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Implementer Focus
Specification S ifi ti iis written itt ffor one target t t audience: di implementers Rationale, Rationale modeling approaches, approaches etc etc. kept elsewhere Multiple reference implementations from day 1 Publiclyy available test servers Starter APIs published with spec Delphi, C#, Java – more to come Connectathons to verify specification approaches Instances you can read and understand L t off examples Lots l (and ( d th they’re ’ valid lid ttoo))
using HL7.Fhir.Instance.Model; using HL7.Fhir.Instance.Parsers; using HL7.Fhir.Instance.Support; XmlReader xr = XmlReader.Create( new StreamRead IFhirReader r = new XmlFhirReader // JsonTextReader jr = new JsonTe // new StreamRead // IFhirReader r = new JsonFhirRe ErrorList errors = new ErrorList( LabReport rep = (LabReport)Resour Assert.IsTrue(errors.Count() == 0
14
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Support “Common” S Scenarios i
Inclusion of content in core specification is based on “80%” rule
“We only include data elements if we are confident that 80% of implementations maintaining that resource will make use of the element” element Other content pushed to extensions
(more on this later)
Easy to say, governance challenge to achieve
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Web technologies
Instances shared using XML & JSON Collections represented using ATOM
Same technology that gives you your daily news summary Out-of-the-box publish/subscribe
Web calls work the same way they do for Facebook & Twitter Rely on HTTPS, OAuth, etc. for security functions
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Human Readable
CDA taught HL7 a very important lesson
Even if the computers don’t understand 99% of what h t you’re ’ sending, di th that’s t’ ok k if th they can properly l render it to a human clinician
This doesn doesn’tt just hold for documents – important for messages, services, etc. I FHIR, In FHIR every resource is i required i d tto have a human-readable expression
C b Can be di directt rendering d i or h human entered t d
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Freely available
Unencumbered – free for use, no membership required http://hl7.org/fhir
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Governance Oversight TSC
Governance FGB Methodology MnM
Content Core Team
Management FMG
Content Work Groups
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PARADIGMS AND ARCHITECTURES 20 © 2012 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Paradigms
FHIR supports 4 interoperability paradigms
REST
Documents
Messages
Services
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REST
Simple, out-of-the-box interoperability Leverage HTTP: GET, POST, etc. Rest Pre-defined operations
Create,, Read,, Update, p , Delete Also: History, Read Version, Search, Updates, Validate, Conformance & Batch
Works best in environments where control resides on client side and trust relationship exists
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Documents
Similar to CDA Collection of resources bound together
Root is a “Document” resource Just like CDA header
Documents
Sent as an ATOM feed One context Can be signed, authenticated, etc.
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Messages
Similar to v2 and v3 messaging Also a collection of resources as an ATOM feed Allows request/response behavior with q p bundles for both request and response Event driven Event-driven
E.g. Send lab order, get back result
Messages
Can be asynchronous
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Service Oriented A hit t Architecture (SOA)
Do whatever you like
(based on SOA principles) Ultra complex workflows Ultra simple workflows Individual resources or collections (in Atom or other formats) Use HTTP or use something else Only constraint is that you’re passing around FHIR resources in some shape or manner Services
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Paradigms
Regardless off paradigm the content is the same This means it’s straight-forward to share content across paradigms E.g. Receive a lab result in a message. Package it in a discharge summary document It also means constraints can be shared across paradigms E.g. Define a profile for Blood Pressure and use it on resources in messages, documents, REST and services i
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Architectures
FHIR makes no assumptions about the architectural design of systems You can use it for
Light or heavy clients Central server or peer-to-peer sharing Push or pull Query or publish/subscribe Loosely coupled or tightly coupled environments With history tracking or without
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FHIR RESOURCES
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Resources
“Resources” are:
Small logically discrete units of exchange Defined behaviour and meaning Known identity / location Smallest unit of transaction “of interest” to healthcare V2: Sort of like Segments V3 S V3: Sortt off lik like CMETs CMET
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What’s What s a Resource? E Examples l
Administrative
Person, P P Patient, ti t Organization, Facility, Coverage, Invoice Allergy, Problem, Family History, Care Plan Document, Message, Profile Conformance Profile,
Gender
T smallll Too
Electronic Health Record
Too big g
Blood Pressure
Infrastructure
30
Cli i l C Clinical Concepts t
N Non-examples l
Too specific
Intervention
Too broad
100-150 total - ever
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Resources
Resources have 3 parts Defined Structured Data
Extensions Narrative
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Person
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Resource elements
Resources are d R defined fi d as an XML structure t t based on desired wire syntax
Hierarchy of elements Each element has
Name Either a datatype or nested elements Cardinality • All collections are nested in a containing element
Definition RIM mapping app g
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It’s all about the resources . . . Facility
Person
Patient
Lab Report
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FHIR EXTENSIONS
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The Case for Extensions
Extensions are often problematic in existing HL7 specs
Z-segments in v2
What does this mean? • ZSB|20080117|Q^57|4.30^uL ZSB|20080117|Q^57|4 30^uL
Foreign namespaces in CDA/V3
Break schemas
Simple choice – design for absolutely everything or allow extensions
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Extensions without the pain… i
Extensions are built into the wire format
All conformant systems can “handle” any possible extension t i - Just J t a bucket b k t off “other “ th stuff” t ff”
Use mustUnderstand to flag extensions that “ h “change thi things”” Require formal definitions of extensions to be available in interoperability space Extensions rendered in human readable portion
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READING THE FHIR SPEC
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(FHIR home)
39
h http://hl7.org/fhir //hl7 /fhi
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Data types
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Data types (cont (cont’d) d)
Based on w3c schema and ISO data types Stick to the “80% rule” – only expose what most will use D t types Data t can have h extensions t i too t
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Example – CD datatype
ISO
Code, code system, code system name, code system version, e s o , value a ue se set id, d, value a ue se set version, e s o , cod coding g rationale, updateMode, flavorId, nullFlavor, controlAct root & extension, validTime low and high displayName with language and translations originalText with mediaType, language, compression, integrityCheck, thumbnail, description, translations, reference (can be te text, t video, ideo whatever) hate er) Translations (most of same info as code) Source code
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Example – CD datatype
FHIR
Code, code system, code system name, code system version, e s o , value a ue se set id, d, value a ue se set version e s o cod coding g rationale, updateMode, flavorId, nullFlavor, controlAct root & extension, validTime low and high displayName with language and translations originalText with mediaType, language, compression, integrityCheck, thumbnail, description, translations, reference (can be text, te t video, ideo whatever) hate er) Translations (most of same info as code) Source code
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Vocabulary
Support for coded data of varying complexity Some codes defined as part of resource, others referenced from external vocabularies
LOINC, SNOMED, UCUM, etc.
Recognition some will differ by implementation space Can use Value Set resource to define more complex p code lists
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FHIR Document
A point in time collection of resources
Can be a ‘stand stand alone’ alone document (like CDA) or a aggregated resource type ( ft profiled) (often fil d)
‘child’ resources are like CDA sections
Atom Document Resource Document Resource Document
Resource 1 Resource 2
4 5
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FHIR Message Atom
Collection of resources sent as a result of some real-world event intended to accomplish a particular purpose
Event Codes & Definitions, like HL7 v2
V2 segments broadly map to resources
Includes a “Message” resource, similar in purpose to Message wrapper and d MSH segmentt
May have associated behavior
Can be conveyed via MLLP, SOAP or other th means
Message Resource Message Resource
Resource 1 Resource 2
4 6
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Profiles
47
Document constraints and extensions on one or more resources May also define new extensions search terms, new messaging events, etc. Subsumes: template, implementation profile, DCM (Detailed Clinical Model), etc. Looks an awful lot like the definition of the resources themselves
You can download profile XML for all resources
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Profile (cont (cont’d) d)
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Conformance
There’s a resource for documenting conformance to FHIR C b Can be used d ffor:
Stating how a specific system instance behaves Defining how a software system is capable of behaving (including configuration options) Identifying y g a desired set of behavior ((e.g. g RFP))
To declare themselves “FHIR Conformant”, a system must publish a Conformance instance
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Conformance (cont (cont’d) d)
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Resource representations t ti
Each E h resource iis published bli h d with ith severall views i covering i different aspects
UML diagram g Simple pseudo-XML syntax Vocabulary bindings Notes Search Criteria Data dictionary Example instance Schema + Schematron RDF,, XMI,, etc. to come
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(FHIR person)
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Example - Person
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Example - Person
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Example - Person
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Example - Person
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Example - Person
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Example - Person
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LET’S POKE AROUND THE SPEC . . . 59 © 2012 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
HOW DOES FHIR COMPARE?
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• XML with fixed schema • Language-supported parsers & validators • Complex nesting & naming • Semantics vary from clear to obtuse
CDA
Character-delimited No built-in parsers Hard to read/debug Few off-the-shelf F ff th h lf validators lid t Semantics not visible in instance
• XML with fixed schema • Language-supported parsers & validators • Complex C l nesting ti & naming i • Semantics vary from clear to obtuse
FHIR R
v2 v
• • • • •
v3
Wire syntax
• XML & JSON with fixed schema • Language-supported parsers & validators • Simple structure • Semantics clear in instance
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CDA
• Primarily messaging • Supports documents (CDA and other) • Sometimes used in services • Frequently no wire compatibility between paradigm representations
• Document only • Some external infrastructure g like allows sort of treating messages or services, but not well-suited
FHIR R
v2 v
• Messaging only • Documents as blobs in an OBX segment
v3
Paradigms
• Supports REST, Message, Document and Services • Wire format (and profiles) consistent across paradigms
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CDA
• Few, if any examples at Int’l level • Minimal tooling support • Implementation varies significantly by jurisdiction
• S Some examples l • Discussion groups available, though often design rather p than implementation-focused • Some tooling, not yet robust • Some 3rd party testing • Some connectathons
FHIR R
v2 v
• Some examples, not necessarily valid • Good G d industry i d t supportt from f 3rd party engines
v3
Implementer support
• • • • •
Lots of examples Reference implementations Public validation servers Generated APIs Connectathons
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CDA
• Int’l specs generally require significant profiling for use • Profiling often done as redesign without wire compatibility • Little direct uptake of int’l specs
• B Base specification ifi ti ttoo complex to implement directly • Popular templates such as g y CCDA are largely interoperable • Human-to-human interoperability provided
FHIR R
v2 v
• Si Significant ifi t configuration fi ti or interface engines required for interoperability • Must be p profiled to be reasonably implemented • Few standard profiles available
v3
Directly interoperable
• Useful clinical interoperability out-of-the-box • Human-to-human interoperability provided • Extensions don’t block interoperability
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CDA
• Extension via foreign namespace or special attribute • Semantics usually, not always, conveyed by element name • Extensions break schemas
• E Extension t i via i fforeign i namespace or special attribute y, not • Semantics usually, always, conveyed by element name • Extensions break schemas
FHIR R
v2 v
• Z-segments allow extension, but only link to extended content is p positional • No extensions to data types • Extensions are opaque
v3
Extensibility
• Extensions built into schema • Extensions formally defined accessible online and reusable
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v2 v
• No consistent syntax for human readability • Can be provided by sitespecific ifi agreementt using i (abusing?) NTE, OBX or Zsegments
CDA
• Human readability a required partt off specification ifi ti
v3
• Not generally designed with human readability in mind • Can be supported if designers accommodate it or extensions used
FHIR R
Human Readability
• Human readability a required part of specification
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• Formal data model • Fully expressive of semantics
CDA
• N No fformall d data t model d l • Inconsistencies in data representation and granularity g between segments • Semantics come from definitions with varying levels of quality
• F Formall data d t model d l • Fixed in time to old version • Limited semantic p expressiveness in some situations • (May be addressed in new version)
FHIR R
v3
v2 v
Robust Semantics
• Full mapping to formal data model where relevant • May map to multiple reference models (e.g. RIM + OpenEHR)
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So if FHIR’s so great, why would we do anything else?
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v2 v
• De facto standard for ininstitution communication • Standard in manyy countries for cross-institution communication
CDA
• High market penetration, particularly of CCD and CCDA g variants due to meaningful use • Significant on-going growth
v3
• Mandated use in a few jurisdictions • Little uptake outside of those mandates
FHIR R
Market Share
• None
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CDA
• In development for over 13 years • Some specifications have had multiple releases • Limited uptake
• In use for over 12 years • Implemented in a variety of settings allll around tti d the th world ld
FHIR R
v2 v
• IIn use for f over 25 years • Broadly supported by industry tools • Now on • Familiarity with both capabilities and limitations (and work-arounds)
v3
Maturity
• First thought of less than 2 years ago • Will go to first DSTU ballot later this year • Won’t be a normative spec for years minimum several more years,
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Simple message
Yes, FHIR has the potential to supplant HL7 v3, CDA and even v2 H However
No one's N ' going i tto th throw away th their i iinvestment t t iin older standards to use FHIR until 1 1. 2.
71
It’s not going to do so any time soon
The specification has a good track record It’s clear the new thing provides significant benefits
HL7 will support existing product lines so long as the market needs them
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FHIR & other SDOs
IHE
DICOM
interested - RESTful access to image metadata
W3C
investigating - use of FHIR for MHD (mobile XDS)
Semantic health group helping us with RDF, RIMbased semantic checking
Because FHIR is free and because of how it’s structured,, use byy other SDOs is certainlyy possible
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IMPLEMENTING FHIR
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Where can FHIR be used? d?
Classic in-institution interoperability Back-end e-business systems (e.g. financial) Regional Health Information Organizations ( (RHIO) ) National EHR systems Social Web (Health) Near Mobile Applications Term
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Migration
Realistically, we don’t expect anyone to migrate existing interfaces any time soon. Initial adopters will be green-field, new technology FHIR may see use behind the scenes in v2 systems before it sees use over the wire
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Migration – v2
Already have an integration engine that supports translation between v2 and FHIR Resources map to segments reasonably well As always, y , the challenge g with v2 mapping pp g is the variability of v2 interfaces
“Common” mappings can be created, but they won’t be one size fits all
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Migration – v3
V3 migrations should be more straightforward as semantics are clear
Migrations will tend to be based on templates and realm constraints rather than international specs
R Round-trip d t i transforms t f are possible ibl
Which get targeted first will depend on implementer desires
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Migration – CDA
Made more complex by human-readable nature
Need to ensure text entry linkages are retained
Will best b t be b handled h dl d on a template t l t by b template basis
Lik l start with Likely i h iimportant ones lik like C C-CDA CDA
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WHAT’S NEXT?
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Balloting plans
2nd 2 d “D “Draft ft ffor C Comment” t” b ballot ll t jjustt closed l d Next cycle will be first Draft Standard for Trial Use ballot (DSTU)
Will likely take ~1 year to complete that process Will provide a semi-stable platform for implementers while still allowing non non-backward-compatible backward compatible change for Normative version if implementation experience dictates
Normative is probably 3+ years out
We want *lots* of implementation experience before committing to backward compatibility
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Development plans
Address issues coming out of this ballot cycle
Add in i many more clinical li i l resources
>500 comments raised Hope to have full support for C-CDA for DSTU
Additionall resources will Additi ill continue ti tto b be introduced in future DSTU cycles as implementers identify needs Continue to seek testing & real world implementation experience
81 © 2012 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Next Steps for you
Attend Att d th the FHIR IImplementers l t tutorial t t i l Read the spec: http://hl7.org/fhir Comment on the wiki (link from FHIR spec) Follow #FHIR on Twitter Shape the specification:
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Join the FHIR track at this WGM Join the FHIR email list http://wiki hl7 org/index php?title=FHIR email list subscription in http://wiki.hl7.org/index.php?title=FHIR_email_list_subscription_in structions Try implementing it M k Ballot Make B ll t comments t Come to a Connectathon!
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REVIEW
© 2012 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
What does FHIR provide? id ?
Resources (building blocks) Extensions Methodology
Bundles,, Profiles,, Conformance
Syntax (XML, JSON) Human readability Support for multiple Paradigms
REST M REST, Messaging, i D Documents, t S Services i
84 © 2012 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
FHIR Manifesto
Focus on Implementers Target support for common scenarios Leverage cross-industry web technologies Require human readability as base level of interoperability Make content freely available Support multiple paradigms & architectures D Demonstrate t t best b t practice ti governance
© 2012 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Questions?
http://hl7.org/fhir
86 © 2012 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
