interopen fhir curation workfhir profile first of type implementation sites gdes trusts + acute eprs...
TRANSCRIPT
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INTEROPen FHIR Curation WorkDr. Munish Jokhani – FHIR Curation Clinical Engagement Lead, NHS Digital
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Agenda
• Use cases(Transfer of Care & GP Connect)
• What is FHIR curation/Why do we need curation?
• How: Overall curation process• Examples
• Next steps and Summary
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Transfer of Care
eDischarge Summary
Mental health eDischarge
Emergency Care eDischarge
Outpatient letters
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GP connect vision
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What is FHIR Curation/Why do we need it?• What :
• Mapping use cases to FHIR resources (with SNOMED CT bindings).
• Why: – The curation process will produce a FHIR profile that is fit for purpose as it has had
clinical, terminology, technical and vendor input.
– It helps those who will be implementing the headings understand the rationale and details behind the content. It also challenges the clinical requirements where they are insufficiently detailed, resulting in a more robust definition.
– Supports consistency in the FHIR profiles and the value sets used; this supports interoperability.
– Create a working group of clinicians, clinical informaticians, technical modellers , terminologists, clinical safety and vendors working together and sharing and best practice.
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Key inputs
● Strategic Overview
● Use Cases including description of clinical workflows and key
interactions
● Clinically assured (e.g. PRSB) Information models/datasets
● Patient journeys with example clinical content
● Architecture overview
● Initial list of FHIR resources for use cases
● Initial plan including deployment approach
● List of engaged vendors and First of Type sites
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How?
CLINICAL MODELLING
e.g. Allergies and adverse reactions
In eDischarge summary
CareConnect FHIR Profile
First of Type Implementation Sites
GDEs TRUSTS + ACUTE EPRS + GP Vendors
PHASE 1 mapping proposal
CLINICAL(PRSB)FHIR TECHNICALTERMINOLOGY
CLINICAL SAFETY
PHASE 2INTEROPen communityFeedback(e.g. Vendors)
PHASE 3 approvedINTEROPen webex call
or workshop
Maintenance
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Vendors
• EMIS, Vision, Microtest
• Cerner, Epic, DXC, Stalis, IMS Maxims, OpenEHR
• Orion, InterSystems, Healthcare Gateway
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Resources completed
Patient Medication Statement
Practitioner Medication
Encounter Medication Request
Practitioner Role AllergyIntolerance
Location Condition
Organisation Procedure
Composition
List
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Example: Clinical Information Model :Allergies and adverse reactions
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AllergyIntolerance
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Active Allergies :Transfer of care
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Allergies Negation:Transfer of care
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Key outputs
● Design Decision Matrix (DDM) with agreed design decisions/actions
(e.g. FHIR extensions, cardinality restrictions, valusets etc.)
● Agreed SNOMED CT/dm+d value sets/refsets
● Implementation guidance
● Changes in the proposed information models
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Design Decision Matrix
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Published CareConnect Profiles
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Next Steps
• Reasonable Adjustments
• Digital Medicines : Pharmacy to GP
• Digital Child Health
• Pipeline e.g. Maternity, Pathology
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Links
• Lessons Learnt Presentation
• Full Feedback Results
• NHS Digital Recognition Award
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Summary and Next steps
• Collaborative and constructive consultation process with wide & enthusiastic Participation.
• Transition to Business as Usual/Service with revised process and review tooling.
• Essential. No one organisation could do it with any hope of a workable outcome.
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FHIR ReviewDr. David Hay – FHIR Strategist, Orion Health
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About me
▸ Medical Doctor
▸ Chair Emeritus of HL7 New Zealand
▸ Co-chair FHIR Management Group
▸ Product Strategist Orion Health
▸ Blog: fhirblog.com
▸ Tooling: clinFHIR.com
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FHIR review
• Review of FHIR Basics
• Exchange Paradigms
• Documents
• GDPR
• Associated standards
• Profiling
• Where is FHIR going
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What is FHIR
‣ Fast Healthcare Interoperability Resources
‣ An HL7 Interoperability Standard
‣ For sharing clinical and administrative information
‣ 2 main parts
‣ Content Model (Resources)
‣ Exchange Specification
‣ Supported by a (very) large community
‣ Chat.fhir.org
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Where does FHIR fit with other HL7 standards?
1980 1990 2000 2010 2020
FHIR
CDA
V3
V2
V2
1987
Start V3
1995
V3 CDA
2005
Fresh Look
2011
FHIR Release 3
2016
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Resources: What are they?
‣ The Content model
‣ The Thing that is exchanged
- Via REST ( FHIR Restful API), Messages, Documents
‣ Informed by much past work inside & outside of HL7
- HL7: version 2, version 3 (RIM), CDA
- Other SDO: openEHR, CIMI, ISO 13606, IHE, DICOM
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Clinical Resource types
General
AllergyIntolerance
Condition (Problem)
Procedure
ClinicalImpression
FamilyMemberHistory
RiskAssessment
DetectedIssue
Care Provision
CarePlan
CareTeam
Goal
ReferralRequest
ProcedureRequest
NutritionOrder
VisionPrescription
Medication & Immunization
Medication
MedicationRequest
MedicationAdministration
MedicationDispense
MedicationStatement
Immunization
ImmunizationRecommendation
Diagnostics
Observation
DiagnosticReport
ProcedureRequest
Specimen
BodySite
ImagingStudy
Sequence
Maturity model
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Resource instance example
Resource Identity &
Metadata
Human Readable
Summary
Extension with URL to
definition
Structured Data:
• MRN
• Name
• Gender
• Birth Date
• Provider
XML and JSON
<valueString value=“jedi”/>
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References between Resources
Patient
Diagnostic reportCondition
Subject
ReportReason
EncounterPerformer
Encounter PractitionerLocation
PROCEDURE
Location
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Resource type structure in the spec
‣ Datatypes in resource type
definition
- Backbone element
- ‘choice’ data types
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Data types: Primitive
Based on w3c schema and ISO data types
▸ Stick to the “80% rule” – only expose what most will use
– Simplified
instant
Value : xs : dataTime 0..1
time
Value : xs : Time 0..1
date
Value : xs:gYear [xs:gYearMonth | Time 0..1
dateTime
Value : xs:gYear [xs:gYearMonth | xs:date | Time 0..1
decimal
Value : xs : decimal 0..1
integer
Value : xs : int 0..1
Element
Extension : Extension 0..
boolean
value : xs:boolean 0..1
string
Value : xs :string 0..1
uri
Value : xs :anyURI 0..1
base64Binary
Value : xs : base64Binary 0..1
unsignedint positiveInt code id oid
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Ratio
numerator: Quality [0..1]
denominator: Quantity [0..1]
Quantity
value: decimal [0..1]
comparator: code [0..1] QuantityComparator!
units: string [0...1]
system: uri [0..1]
code: code [0..1]
Range
low: Quantity(SimpleQuantity) [0..1]
high: Quantity(SimpleQuantity) [0..1]
HumanName
use: code [0..1] NameUse!
text: String [0..1]
family: String [0..*]
given: String [0..*]
prefix: String [0..*]
suffix: String [0..*]
period: Period [0..1]
Identifier
use: code [0..1] IdentifierUse!
type: CodeableConcept [0..1] IdentifierType+
system: uri [0..1]
value: String [0..1]
period: Period [0..1]
assigner: Reference [0..1] Organization
Address
use: code [0..1] AddressUse!
type: code [0..1] AddressType!
text: string [0..1]
line: string [0..*]
city: string [0..1]
district: string [0..1]
state: string [0..1]
postalCode: string [0..1]
country: string [0..1]
period: Period 0...1
Coding
system: uri [0..1]
version: string [0..1]
code: code [0..1]
display: String [0..1]
userSelected: boolean [0..1]
Elementextension:
Extension 0..*
Timing
event: dataTime [0..*]
code: CodeableConcept [0..1] TimingAbbreviation?
Repeat
bounds[x]: Type [0..1] Duration|Range|Period
dount: Integer [0..1]
dountMax: integer [0..1]
duration: decimal [0..1]
durationMax: decimal [0..1]
durationUnit: code [0..1] UnitsOfTime!
frequency: integer [0..1]
frequencyMax: integer [0..1]
period: decimal [0..1]
periodMax: [0..1]
periodUnit: code [0..1] UnitsOfTime
dayOfWeek: code [0..*] DaysOfWeek!
timeOfDay: time [0..*]
when: Code [0..*] EventTiming!
offset: unsginedInt [0..1]
ContactPoint
system: Code [0..1] ContactPointSystem!
value: String [0..1]
use: Code [0..1] ContactPointUse!
rank: PositiveInt [0...1]
period: Period [0..1]
CodeableConcept
coding: Coding [0..*]
text: String [0..1]
Attachment
contentType: Code [0..1] MimeType!
language: Code [0..1] CommonLanguages+
data: base64Binary [0..1]
url: uri [0..1]
size: unsignedInt [0..1]
hash: base64binary [0..1]
title: string [0..1]
creation: dateTime [0..1]
Period
start: dateTime [0..1]
end: dateTime [0..1]
SampledData
origin: Quantity(SimpleQuantity) [1..1]
period: Decimal [1..1]
factor: Decimal [0..1]
lowerLimit: Decimal [0..1]
upperLimit: Decial [0..1]
dimensions: Positivelnt [1..1]
data: String [1..1]
Data types: Complex
Signature
type:Coding [1..*] Signature Type?
when: Instant [1..1]
who[x]: Type [1..1] uri |
Reference(Practitioner|Related
person|PatientDevice|Organization)
onBehalfOf[x]: Type [0..1]
uri|Reference(Practitioner|RelatedPers
on|Pateint|Device|Organization)
contentType: code [0..1] MimeType!
blob: base64Binary [0..1]
Annotation
author[x]: Type [0..1]
Reference(Practitioner|Patient|
RelatedPerson)|string
Time: dateTime [0..1]
Text: string [1..1]
repeat
[0..1]
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Complex datatype example: HumanName
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Terminology: FHIR and SNOMED
Code System:
Defines a set of
concepts with a
coherent meaning
eg SNOMED
Value Set:
A selection of a set
of codes for use in a
particular context
Eg
Condition.verificationStatus
Coded Element
Core resource or
profileSelects Binds
Refers to
Conforms
Definition
Resource Instance
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ValueSet
‣ Used in Coded elements
‣ A set of possible values for
a resource element
‣ Key component of
Terminology
‣ Similar to SNOMED refset
‣ Can be altered in profiling
(Curation)
‣ Eg:
Condition.verificationStatus
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Terminology binding: Condition resource ▸ a
View in spec…
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Exchange Paradigms
REST
DocumentsMessages
Services (Operations)
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Sharing information – different paradigms
REST
Message
FHIR
Repository
Document
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Documents in FHIR
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What is a Document?
▸ Clinically
– Summary at a point in time
– Eg eDischarge. Mental Health, Emergency
Care eDischarge, Outpatient letters
▸ Contents
– Metadata
• Name, Author, Document type
– Sections with clinical data
• Eg Meds on Admission, Reason for
admission
– Can have signature
▸ HL7: What is a Document
– Persistence
– Stewardship
– Potential for
Authentication
– Context
– Wholeness
– Human readability
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FHIR Document paradigm
‣ Technically a collection of
resources in a Bundle
‣ Can be signed
‣ Narrative in Composition
‣ Rendering rules in spec
Patient
Practitioner
Condition
List
AllergyIntolerance
Composition
• Subject
• Author
• Sections
• Admit Dx
• Allergy List
• … AllergyIntolerance
Document Bundle
http://hl7.org/fhir/documents.html
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GDPR (General Data Protection Regulations)
▸ FHIR is not a security standard, but…
▸ Discussions at the Connectathon last week:
– Existing privacy well aligned
(https://healthcaresecprivacy.blogspot.co.uk/2015/04/privacy-principles.html)
▸ Current FHIR support:
– AuditEvent, Provenance, Consent
– Any resource has security tags
– Authentication/Authorization
• SMART on FHIR, Pages in spec
– Identity resources
• Patient, RelatedPerson, Practitioner, Organization & others…
▸ Some gaps and areas for improvement
– White paper to come
https://healthcaresecprivacy.blogspot.co.uk/2018/05/gdpr-on-fhir.html
https://chat.fhir.org/#narrow/stream/111-Security-and.20Privacy
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SMART
▸ Substitutable Medical Applications, Reusable Technologies
– http://hl7.org/fhir/smart-app-launch/
▸ History
▸ Originally limited to EHR external apps
– Becoming the ‘de-facto’ Authentication
▸ 2 aspects
– App launching
• Public & confidential
– Authentication ‘Profile’ on OAuth2 & OpenID Connect
• Endpoints and scopes
▸ Sandbox: https://sandbox.smarthealthit.org/#/start
▸ App Gallery: https://apps.smarthealthit.org/
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CDS Hooks
▸ Clinical Decision Support (CDS)
– User Interface for display CDS
– ‘hooks’ to EHR activity
▸ Service can call back to EHR
– Or any other data store
▸ Discovery & endpoints
▸ Prefetch
▸ Security Model
– ‘out of band’ setup
• Key exchange
– TLS
– Encrypted JWT in call to
service
– Access token provided for call
back
http://cds-hooks.org/specification/1.0/
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Blockchain
▸ Technology behind bitcoin
▸ Distributed list of transactions (blocks)
▸ Cryptographically signed
– Can’t change without detection
▸ What is relationship with FHIR?
– Unlikely actual clinical data
– Tamper proof audit records
– Provider Authentication
– Supply chain (eg medication
provenance)
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Adapting FHIR to your needs: Profiling
‣ Many different contexts (ways of recording data) in healthcare, but want a single set of Resources
‣ Need to be able to describe ‘usage of FHIR’ based on context
‣ Allow for these usage statements to:
- Authored in a structured manner
- Published in a registry & Discoverable
- Used as the basis for validation, code, report and UI generation.
‣ 3 main aspects:
- Constraining a resource - remove element, change multiplicity fix values
- Change coded element binding
- Adding a new element (an extension)
‣ Profiling adapts FHIR for specific scenarios
‣ A Statement of Use
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For example…
Limit names to
just 1 (instead
of 0..*)
Change
maritalStatus to
another set of
codes that
extends the one
from HL7
international
Require that the
identifier uses the
NHS number – and is
required
Don’t support
photo
Add an
extension
to support
ethnicity
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Where is FHIR going
‣ More resources
‣ Moving resources to normative
‣ More implementation experience, Connectathons
‣ Moving beyond Interoperability
‣ Extending into Clinical Knowledge
‣ Decision Support, Quality Measures
‣ Also being used for persistence
‣ Definitional resources, Care planning & support
‣ Associated standards
‣ SMART
‣ CDS-Hooks
‣ FHIR Cast
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UK approach: Building the community
▸ INTEROPen
– Clinical curation of profiles
– Clinician involvement
– Multi discipline
– Vendor involvement
▸ NHS Digital
– Technical expertise
▸ Standards being developed
– Transfer of Care
▸ Propose Connectathon
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Reality Check
▸ Sounds wonderful!
▸ Managing Expectations
▸ Analogy of building house
▸ All this is the concept plan…
▸ What does FHIR really stand for?
Far Harder In Real life !
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52
Clinicians on FHIR: Modelling the
Problem ListDr. Amir Mehrkar – GP | Co-Chair INTEROPen
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A variety of views
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Encounters with patientsEncounter 1
(Date/Time)
Encounter n
(Date/Time)
NOW 4 episodes “a Problem”As a problem, has own life cycle management:
● Start date as a problem
● End date as a problem
● Who said this is a problem
○ Clinician / Patient
○ Organisation
● Status - is it still a problem?
● Significance of the problem
○ Major Depression diagnosis but
might be a minor “problem” for
patient
● Associated data
● Nested, Merge, Evolving
When does it become a “Problem”
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Status (active / inactive)
Significance (major / minor) Types of Problems
The actual Problem can have its own FHIR data model
● Gastro-oesophogeal reflux - Condition resource
● Fam History of Scleroderma - may not exist as a
simple pre-coordinated code
● Procedures (Left / Right - post-coordinated)
● What resource type would Dizziness sit in?
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Nesting of Problems
Dizziness / Lethargy / Suicidal thoughts
are independent Problems for the patient
BUT
Clinician creating the Problem List believes they
are related to the patient’s “Marital breakdown”
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“Merge/Combine” Or “Evolve” Problems
Merge/Combine
Evolve
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List
Resource
Type
‘ProblemHeader Profile’ (a profile of Condition Resource)
Keep: onset; abatement; asserter/date; note; ClinicalStatus (active/inactive only for now)
Remove: evidence; bodysite; severity; stage; verification status
Reference any other Resource type:
● Diagnosis -> Condition
● obs/symptom/social -> Observation
● Family History -> FamilyHistoryMember
● Allergy -> AllergyIntolerance
● Issues -> Alert
Extension: Actual Problem
Extension: Related ProblemHeader
Valueset: Nest, Merge, EvolveReference another ProblemHeader Resource type
Extension: Problem Significance
Valueset: Major/Minor
Extension: RelatedClinicalContent Reference Any Resource type
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List
Resource
Type
‘ProblemHeader Profile’ (a profile of Condition Resource)
Keep: onset; abatement; asserter/date; note; ClinicalStatus (active/inactive only for now)
Remove: evidence; bodysite; severity; stage; verification status
Code.text = Human readable rendering
Code.coding if unambiguous code
Reference any other Resource type:
● Diagnosis -> Condition
● obs/symptom/social -> Observation
● Family History -> FamilyHistoryMember
● Allergy -> AllergyIntolerance
● Issues -> Alert
Extension: Actual Problem
Extension: Related ProblemHeader
Code (Nesting, Merge/Combine, Evolve)Reference another ProblemHeader Resource type
Extension: Problem Significance
Code (Major/Minor)
Extension: RelatedClinicalContent Reference Any Resource type
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62
ClinFHIR ConMan:
Clinicial Model ValidationDr. David Hay – FHIR Strategist, Orion Health
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History of clinFHIR
▸ ClinFHIR Purpose
– Assist resource development (HL7 Working Group Meeting)
– Educational
– Clinician/Business Analyst tool for participation in FHIR projects
– Develop simple FHIR artifacts
• Eg simple Profiles, ValueSets, Extension Definitions
– 2 modules using today
• ConMan
– Developed to support technical Connectathon
– Extended to Clinicians On FHIR events
• Logical modeler
– Build ad-hoc ‘things’ to use in Scenario (eg representing a potential
Profile)
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Connectathon
▸ What is a connectathon
▸ Technical and Clinical tracks
▸ Technical tracks
– Enhance specification
▸ Clinical tracks:
– Purpose
• Education
• Gather clinical requirements
• Validate artifacts
– Precursor to Profile, IG
– Clinical Track types
• Scenario
• Model reviewFocus for today: Education
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ConMan structure
TrackTrack
(Problem List)
TrackScenario
(eg simple List)
TrackScenario
Instance Graph
Over to Amir…
http://snapp.clinfhir.com/connectathon.html?event=cofio