fhir-documents
- 1. FHIR® is the registered trademark of HL7 and is used with the permission of HL7. The Flame Design mark is the registered trademark of HL7 and is used with the permission of HL7. Amsterdam, 15-17 November | @fhir_furore | #fhirdevdays17 | www.fhirdevdays.com FHIR Documents Rick Geimer, Chief Innovation Officer, Lantana Consulting Group
- 2. Instructor • Rick Geimer • Co-Chair Structured Documents Working Group • HL7 CDA R2 Certified Specialist • Co-Editor, CDA Consolidation and many other implementation guides • Lead: C-CDA on FHIR project • Day job: Chief Innovation Officer, Lantana Consulting Group • rick.geimer@lantanagroup.com
- 3. Lantana Consulting Group • Our Mission • Improve healthcare through health information technology (IT) • Lead the industry through consulting and volunteer practice • Our Services • Software and standard development and implementation • Terminology, data governance, and education • Strategic advice for health IT planning, design, and purchasing
- 4. Outline • Overview of Clinical Documents • FHIR Documents • The Composition Resource • Document Bundles • Document Operations and APIs
- 5. Clinical Documents • This is a document • and this • and this • and this • and this • and this
- 6. Clinical Documents • Persistence – A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements. Note: documents outlive the servers (and often the syntax) on which they are created. • Stewardship – A clinical document is maintained by an organization entrusted with its care. • Potential for authentication – A clinical document is an assemblage of information that is intended to be legally authenticated. • Context – A clinical document establishes the default context for its contents. • Wholeness – Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document. • Human readability – A clinical document is human-readable.
- 7. Why are documents important? • The clinical record has a dual nature • Data • Narrative • Documents support that duality • Essential for disparate teams—different disciplines, contexts, or clinical systems • Developers need coded data to drive applications • Clinicians often say that the most important part of the clinical record is the narrative written by their colleagues
- 9. FHIR Documents • Position: FHIR is the document future • Call to action: • Define, document, and promote a future where clinical documents and Application Programming Interfaces (APIs) share a common syntax and set of resources • Establish, in technical and regulatory policy, a smooth roadmap to the future of clinical document exchange
- 10. FHIR Documents • Address CDA use case for clinical documents • Collection of resources bound together • Root is a Composition resource • Much like the CDA header + narrative • Sent as a Bundle resource • Can be signed, authenticated, etc. • Has the same basic obligations as a CDA document • Full rules: http://build.fhir.org/documents.html
- 11. Why FHIR Developers Might be Interested in Documents • Load FHIR servers with massive amounts of existing data • Most electronic health record (EHR) systems export CDA • Their CDA export capabilities are more stable than many of their FHIR APIs (if any) • Converting CDA to FHIR is one of the quickest standardized path to Big Data in healthcare today • Comply with existing requirements • FHIR is simpler than CDA • Teach developers to create FHIR documents, then convert to CDA for compliance with existing regulations • FHIR as an API for creating CDA documents • Prepare for when FHIR documents are the norm
- 12. <Bundle> <entry> <Composition /> </entry> <entry> <Observation /> </entry> <entry> <Device /> </entry> <entry> <Prescription /> </entry> <entry> <Patient /> </entry> </Bundle> Observation Resource Composition Resource Section Section Device Resource Patient Resource Prescription Resource AttesterMetadata FHIR Documents are Bundles of Resources
- 13. Composition Resource • Contains • Patient • Author • Custodian • Type of document (e.g., Discharge Summary) • Attested narrative of the document • Sufficient for • Medical records management • Document management • Enabling clinical document exchange across and within institutions • Human readable documents Chart Clinical Documents
- 14. Composition in Detail • Key fields • Identifier • Date • Type • Subject • Author • Attester • Custodian • Sections and narrative • References to other resources
- 15. Sections and Narrative • Composition resources contain sections (which may be nested) • Section narrative markup is XHTML • Narrative contains the attested text of the document • OK for sections to consist of only human readable text (i.e., no machine processable resources)
- 16. First: Human Readable <section> <title value="Allergies and Intolerances"/> <code> <coding> <system value="http://loinc.org"/> <code value="48765-2"/> <display value="Allergies and adverse reactions"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <ul> <li>Penicillin - Hives</li> ... </ul> </div> </text> ... </section> Allergies and Intolerances • Penicillin - Hives
- 17. <AllergyIntolerance xmlns="http://hl7.org/fhir"> <clinicalStatus value="active"/> <verificationStatus value="confirmed"/> <category value="medication"/> <criticality value="high"/> <code> <coding> <system value="http://snomed.info/sct"/> <code value="418038007"/> <display value="allergy to penicillin"/> </coding> </code> <patient> Next, Coded Data <assertedDate value="2000"/> <reaction> <manifestation> <coding> <system value="http://snomed.info/sct"/> <code value="247472004"/> <display value="hives"/> </coding> </manifestation> <severity value="mild"/> </reaction> </AllergyIntolerance>
- 18. A Bit of Bundle • Type = document • Bundle.identifier • Version dependent • Must be globally unique to satisfy the persistence requirement • First resource is Composition • Documents must be standalone, so… • The Bundle should (some would say must) contain all resources referenced from the Composition
- 19. <?xml version="1.0" encoding="UTF-8"?> <Bundle xmlns="http://hl7.org/fhir"> <id value="ee5590ab-72c0-4c07-9dc0-cc574729cd0a"/> <type value="document"/> <entry> <fullUrl value="urn:uuid:511b05b3-8c3d-4cbe-b9d8-fe5f8666f994"/> <resource> <Composition> <subject> <reference value="urn:uuid:9f334dba-57b1-47bf-a2ba-a60d9583c8bb"/> </subject> ... </Composition> </resource> </entry> <entry> <fullUrl value="urn:uuid:9f334dba-57b1-47bf-a2ba-a60d9583c8bb"/> <resource> <Patient>...</Patient> </resource> </entry> </Bundle> References in Bundles This example shows UUID URIs, but can be a FHIR server URL such as http://example.org/fhir/Patient/1
- 20. Rendering FHIR Documents • When the document is presented for human consumption, applications SHOULD present the collated narrative portions in order: • Subject resource Narrative • Composition resource Narrative • section.text Narratives • Reference stylesheet (XSLT) • Document2HTML.xslt in the XML Tools download • http://hl7.org/fhir/downloads.html
- 21. Demonstration • Review a FHIR Document Bundle
- 22. FHIR APIs • REST = “Representational state transfer” (an architecture for how to connect systems) • Based on HTTP, the protocol that powers the Web • Outcomes • Simple stable interfaces • High performance / scalability • Visible process (e.g., can debug) • Portability • Reliability (resistance to failure) • REST in FHIR • The FHIR API is composed of RESTful web services
- 23. FHIR RESTful URLs • CRUD(E) operations mapped to HTTP • Create new resource: POST to the resource type endpoint • Read existing resource: GET • Update existing resource: PUT • Delete existing resource: DELETE • Execute: Use $operations in the URL https://server.org/fhir/Patient/1 endpoint resource type id
- 24. Documents and FHIR APIs • Generating documents • Call $document on a Composition resource • Stores at the /Bundle endpoint if persist=true • Moving documents or storing externally created documents • Send to /Bundle or /Binary depending on use case • Use PUT to preserve IDs when sending to /Bundle (First, make sure globally unique) • Decomposing documents • POST to the transaction endpoint (May need to be converted to a transaction bundle first)
- 25. Managing FHIR Documents • To satisfy the persistence and stewardship requirements, documents must be stored somewhere (or reproduced on demand) • The easiest way is on a FHIR server directly, either at the Bundle or Binary endpoint • Other options include document management systems, clinical data repositories, etc. • Important: documents (especially attested ones) should not be generated, transmitted, then disposed of like a transient message
- 26. Validating FHIR Documents • FHIR validation pack • Includes XML Schema and Schematron files • http://build.fhir.org/fhir-all-xsd.zip • The FHIR Validator • A Java JAR file that runs full FHIR validation • http://build.fhir.org/validator.zip • FHIR server validation • Most servers to basic resource validation • Use the $validate operation • Can validate profiles like C-CDA on FHIR • http://build.fhir.org/operation-resource-validate.html
- 27. Resources • The FHIR specification • Updated continuously • Latest balloted version: http://hl7.org/fhir • Continuous build: http://build.fhir.org/ • “FHIR CDA Position Statement and Roadmap” Lantana white paper co-authored with Grahame Grieve; Updated April, 2015 • http://www.lantanagroup.com/resources/publications/ • Rick Geimer • Updated continuously, rebooted occasionally • rick.geimer@lantanagroup.com