Getting SMART with FHIR - HISA
Transcript of Getting SMART with FHIR - HISA
Australia’s National Science Agency
Getting SMART with FHIR
Grahame Grieve, Mark Braunstein, Michael Lawley, Brett Esler, Reuben Daniels, Kate Ebrill, Steve Badham, Andrew Patterson, Danielle Bancroft, Brian PostlethwaiteAugust 2019
1. FHIR rapidly spreading around the World- Grahame Grieve2. Fueling FHIR for change in the US- Mark Braunstein3. Quick FHIR: initiatives across Australia
o HL7 Au - Brett Esler
o SafeScript - Danielle Bancroft
o Federated Provider Directory - Brian Postlethwaite
o National Children’s Digital Health Collaborative - Steve Badham
o Queensland Clinical Terminology Service - Reuben Daniels
o Genomics Alliance’s supported by FHIR - Andrew Patterson
o Primary Care Data Quality and Practice to Practice Exchange - Kate Ebrill
Agenda
Mentimeter- getting to know who is in the room
FHIR: Spreading around the world
Grahame Grieve
13-Aug 2019
Melbourne (IHE/HIC)
FHIR: The web, for Healthcare
Open Community Open Standard
• Make it easier to exchange healthcare information
• Open Participation - uses web infrastructure (social media)
• Lead by HL7 - deeply connected to world wide health community
• Describes how to exchange healthcare information
• A web API - web standards where possible
• Continuity with existing healthcare standards
• Public Treasure (http://hl7.org/fhir)
FHIR History
Standards History
• July 2011 - Conception
• May 2012 - First Milestone
• Sept 2014 - R1 (Trial Use)
• Oct 2015 - R2
• April 2017 - R3 (CC0)
• Dec 2018 - R4 (1st Normative)
• Oct 2020? - R5
Implementation History
• Sept 2012: 1st Connectathon
• June 2014: Commonwell (1st Prod)
• Sept 2014: Reorientate
• Dec 2014: Argonaut
• May 2016: FHIR Foundation
• Jan 2018: Apple Healthkit
• Late 2019?: R4 required in US Regs
Three Legs of the Standards Process
• Base Standard• Establish Capabilities• Common Engineering• V2, FHIR, DICOM, LOINC, SNOMED, XDS?
• Profiling for Communities• Common Use Cases, Smaller communities (Wishel Rule)• Adapt / Combine • IHE, Argonaut / Da Vinci, ADHA / IT-14
• Driving Solutions into the Market• Regulation, Incentive Payments – ONC, ADHA, etc• Trade Associations - HIMSS / HISA,
Overall Progress
Where adoption is happening
• Secondary Data Repositories• Patient access to data• Big Data • Specific Clinical Data Repositories • National Health Records / Sharing frameworks
• Application Extension• Argonaut / EHR Plug-ins• Decision Support Integration
• Primary Apps: SaaS (health)
• Interaction between Payers and Providers (pre-auth, approval, review processes)
Adoption: USA / Argonaut
• Clinical Summary Query (R2 -> R4)
• Provider Directory
• Scheduling
• Clinical Notes
• Questionnaire
• Active Health Nodes – provide services to enable a distributed healthcare system
• Clinical Summary (R4) required in next regulations
Adoption: USA / Da Vinci
• Prior Authorization
• Coverage Decision
• Payer Data Acquisition
• Care Plan / Medicine Formulary Exchange
• Clinical Data/Documentation/Record Exchange
• Alerts
Adoption: USA / Federal
• Blue Button (2) – Government + Payer reporting of payment information)
• Quality Measure (Data Collection / Reporting)
• National Provider Directory
• NIH Endorsement
• Public Health / Death reporting
• VA Clinical care projects
Adoption: US Vendors
• Many personal health projects • Apple Healthkit – expanding scope & range
• Many Data Analytics / Repository Projects• Google Brain Project
• Many Toolkits / Frameworks • SmileCDR (HAPI!)
• Microsoft Azure FHIR Server
Adoption: Europe
• International Patient Summary
• “Document” – clinical summary for a patient
• Corresponds roughly to Argonaut scope
• Packaged as a document, not an API (push)
• Makes rules about terminology (SNOMED CT)
• Not just Europe
• MedMij - Personal health data in the palm of your hand
• Mobile access to all medical data over life time
• MedMij covers legal, organizational, financial, semantic and technical aspects
• 4 year initial project – 2016 - 2020
Adoption: Netherlands
Adoption: England / UK
• Interopen Project
• Renal Clinical Repository
• Many vendor projects
Adoption: Australia
• National Clinical Terminology Service (on Ontoserver)
• Provider Directory Project (supporting secure messaging)
• Document access to MyHR for mobile apps
• Agency strongly interested in FHIR documents going forward
• Lots of internal use in vendors (Telstra Health, Alcidion)
• Some classic interop in GP space• Appointments / decision support
• Not in common use in institutions yet
Common Production Uses for FHIR
• Exchanging Clinical Summary / Clinical Transfer
• EHR Extensibility
• Patient / provider registration
• Data Analytics / Surveillance
• Quality Measures / Clinical Performance
Join Us
• FHIR is a critical infrastructure enabler • A community solution for the IT requirements
• But FHIR is not a solution to anything itself
• Need new community infrastructure at many levels• Governance is critical: Build confidence and trust – open community treasure
• Needs stable Governance foundations with consistent transparency
• Join the community (FHIR, or others) • http://hl7.org/fhir, http://fhir.org
Fueling FHIR for Change in the US
Mark L Braunstein, MDVisiting Scientist
Australian eHealth Research Centre
Professor of the PracticeSchool of Interactive ComputingGeorgia Institute of Technology
2016: 21st Century Cures Act
Interoperability
Data blocking
Patient access (APIs)
2009: American Recovery and Reinvestment Act
EHR Adoption and Meaningful Use
US Federal Interoperability Mandate
2019: Promoting Interoperability (PI) program2014: Argonaut Project
Using FHIR!
“By identifying the FHIR standard to implement our policies, we are promoting scalable data sharing, not just an individual patient record from hospital to hospital but a model that supports the flow of information across the entire healthcare system.”
--CMS Administrator, Seema Verma, HIMSS 2019
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Industry is Aboard
Amazon, Google, IBM, Microsoft, Oracle, and SalesforceCMS Blue Button 2.0 Developer Conference, July 30, 1019
“…we are fortunate to work with many teams and partners that draw on experiences across industries to support and accelerate the delivery of FHIR APIs in healthcare. Moreover, we are committed to introducing tools for the healthcare developer community. After the proposed rule takes effect, we commit to offering technical guidance based on our work including solution architecture diagrams, system narratives, and reference implementations to accelerate deployments for all industry stakeholders. We will work diligently to ensure these blueprints provide a clear and robust path to achieving the spirit of an API-first strategy for healthcare interoperability.”
http://blog.hl7.org/cloud-providers-unite-for-healthcare-interoperability-fhir
App Ecosystems for Providers
… and for Patients
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FHIR Gateway
SMART Apps
What Problems?
https://med.stanford.edu/content/dam/sm/ehr/documents/EHR-Poll-Presentation.pdf
EHRs: Mixed Results
Notes
CC/HPI: Abdominal Aortic Aneurysm Case
Problem Specific Structured Documentation
Key Findings Highlighted
PE: Abdominal Aortic Aneurysm Case
Procedure Reports
Varicose Veins Assessment/Plan
Procedure Note
Questionnaires/Scoring
Quality ofLife Score
Notes Management
Timeline Display
Timeline Standalone
Write-back
FHIR DocumentsDiagnoses/Problems (ICD-10) via FHIR or Proprietary API
• Epic
• Cerner
• Allscripts
• Athena
• Nextgen
Vault: Hierarchical Condiiton Coding
Each HCC is mapped to an ICD-10 code. Along with demographic factors (such as age and gender), insurance companies use HCC coding to assign patients a risk adjustment factor (RAF) score.
PCPs Needs versus Capabilities
Continuous, Coordinated Care
EHR Data
Patient GeneratedData
Integrated patient messaging(provider coming)
Targeted Information
Trend Insights
Suggested Evidenced-based Goals
Predictive Analytics
Estimated A1C on currentversus proposed therapy
Personalized Clinical Decision Support
Automatic Attribution
Medicare
Reduce patient burden
A research organization can pre-populate a medication lists for a patient during clinical trial
enrollment.
Streamline information about different kinds of care over time
A primary care physician can access information on other patient care (e.g. related to behavioral
health) to better inform treatment.
Uncover new insights that can improve health outcomes
A pharmacy can determine if a beneficiary gets healthier over time due to medication
adherence.
Access and monitor health information in one place
A health application can aggregate data into a health dashboard for beneficiaries.
VA API
NIH
Da Vinci Project: Value-based Care
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“The goal is to enable improved patient care outcomes as well as empower better clinical decision making by shifting key information into provider teams’ work flow and sharing that information across organizational boundaries.”
https://www.pocp.com/biopharma-davinci-project
Mentimeter- reflecting on the presentations…
Australian initiatives implementing FHIR
Quick FHIR
Provider
DirectoryCSIRO
Primary Care
AU Base
FHIR Core
Child
Health
AU Standards
AU Argonaut
MedView
• Medication platform using a FHIR server with Cosmos DB
• Framework provides a third party integration platform
• MedsList and MedsRec key apps in ADHA testbed project – real-time discharge and admission between acute and primary care
• Integrated with MyHR for upload of Meds Reconciliation (Pharmacist Shared Medication List – PMSL)
RTPM (SafeScript and NDE)
• Use of medication order and medication dispense order resources for API pre-check
• Investigating EMR FHIR platforms for health service SSO
ePrescribing
• Investigating conformance requirements and currently prototyping workflows.
• Investigating potential use of Azure on FHIR
• HL7 Australia Profile
• Supporting Secure Messaging• ADHA SMD POC
• Federated Deployment
• Service Registration Assistant
• NHSD
• VhDir International Guide
• FHIR STU3 vs R4
FHIR Provider Directories NHSDADHA SRA
Best PracticeTelstra Health
Secure Messaging
HealthLink Secure
Messaging
Global Health
Secure Messaging
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Paper Records Harmonised ContentClinical Information
Specifications & ModelFHIR Implementation Guide
Consumer Held Child Health Record
• Sharing of child health information between consumers and multiple providers
• Jurisdictional Child Health Record (baby book) Custodian
• Full clinical and consumer consultation by each jurisdiction
Harmonised Clinical & Consumer Content
• Nationally agreed core components of a child health record
• Ensure each jurisdiction’s data is represented in the national data set
• CDHR Harmonisation Expert Committee (Jurisdictional Child Health Record Custodians)
• Australian Health Ministers Advisory Council (AHMAC) – Health Services Principal Committee (HSPC)
• Targeted Consultation by jurisdictional Child Health Record custodians
Clinical Information Specifications & Model
• Spec: How the information will be structured in a digital record
• Model: The clinical information presented for clinical review and endorsement
Spec:• Internal Review• Terminology Review by CSIRO
Model:• Clinical Informatics Endorsement
Committee (Peak Bodies & Colleges eg RACGP, RACP, etc)
Spec:• Clinical TIGER team – Clinical
questionsModel:• Endorsed through the organisation’s
standard endorsement process• Reviewed by National Research
Advisory Group to identify research gaps
Child Data Hub to CIS & Consumer App Information Exchange
• Industry agreed specification for the exchange of clinical information
• HL7 Child Health Working Group
• HL7 Australia (International Standard)
• FHIR Implementation Guide profiles based on the HL7 Australia base resources collaboratively developed through the working group
High (≥50% Use) Medium (30-49% Use) Low (<30% Use)
Child InformationNat %
UseW/S
OutcomeBaby's Name 63 CName of Birth Facility 100 ADate of Birth 100 CTime of Birth 75 ASex (Male) 75 CSex (Female) 75 C
Child InformationNat %
UseW/S
OutcomeThis section is to be completed by a health professional
38 E
Baby's Given Name/s 38 CBaby's Family Name 38 CAddress 38 CBaby's Blood Group 38 E
Child InformationNat %
UseW/S
OutcomeUR (Unique Reference) 13 E
Examiner Name 25 E
Maternal InformationNat %
UseW/S
OutcomeMother's Name 63 CPregnancy Complications 63 AMother's Blood Group 63 ELabour (Spontaneous) 63 ALabour (Induced) 63 ALabour (Induced - Reason) 63 AType of Birth (Normal/Vaginal) 75 AType of Birth (Breech) 75 AType of Birth (Forceps) 75 AType of Birth (Caesarean) 75 AType of Birth (Vac Ext) 75 A
Maternal InformationNat %
UseW/S
OutcomeAnti D Given 38 ELabour Complications 38 EType of Bi rth (Home) 38 EType of Bi rth (Other) 38 EType of Bi rth (Other, Specify Details) 38 EPostpartum issues 38 E
Maternal InformationNat %
UseW/S
OutcomeMother's Given Name 25 CMother's Family Name 25 CFather's Name 13 CMother's Date of Birth 13 EMother's Home & Mobile Phone 25 EMRN (medical record number) 25 CType of Bi rth (write) 25 EType of Bi rth (water) 25 EDelayed cord clamp 13 TBirth Complications 25 EMaternal GBS Status 13 EMaternal GBS Status - Antibiotics given? 13 EMaternal rubella TITRE 13 EMother has had in pregnancy (CMV / Toxoplasmosis / Rubella
13 E
Workshop IdentifiedNat %
UseW/S
OutcomeFathers Given & Family Names ASex Other TOther Parent A
LegendA Agreed (Include) AA Agreed for ATSIT To be Agreed C Core DataO Out of Scope E Exclude
CDHR Clinical & Consumer Information Management
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Data Source Conceptual Data Item Logical Data Item Logical Data Item Description Logical Data Item
Code (If
Applicable)
Field Type ValueSet
Elements
ValueSet
Element Code
ValueSet Description Field Type Format Priority Cardinality
Harmonised (H)
Content impacts
from orchestartion
(O) (operational)
(OP)/ (F) FHIR /
restrictions /
enhancements ( E )
BOLD equals
Harmonised data
Name of the Data Item The description of the logical data
item description
SNOMED Code
which represents
the data item
FHIR
Date, text, checkbox,
radio button,
numeric, drop down
list
Name of ValueSet
Element Item
BOLD equals
Harmonised data
SNOMED
Code which
represents the
data item
The description of
the element
Date, text,
checkbox,
radio
button,
numeric,
ValueSet
eg
DD:MM:YYY
Y
Mandatory/
Required/
Optional
Relationshi
p of x to y
eg IHI is 1..1
First Name (Given)
First Name - will represent the
name of baby ie 'Baby of <mother
first name>'
FHIR Text Text String Required 0..1
Last Name (Family)Last Name - will represent the last
name of motherFHIR Text Text String Required 0..1
First Name (Given) First name of Mother FHIR Text Text String Required 0..*
Last Name (Family) Last name of mother FHIR Text Text String Required 0..1
OR
Full Name
Full Name of Mother (used where
First and Last names are not split
into separate fields in a system)
FHIR Text Text String Optional 0..1
*Street Address Street name, number, PO box etc FHIR Text Text String Optional 0..*
City Name of City, Town FHIR Text Text String Optional 0..1
State State in which the baby lives FHIR Text Text String Optional 0..1
Postal Code Postal code for area FHIR Text Text String Optional 0..1
Country Name of Country FHIR Text Text String Optional 0..1
First Name (Given) First name of Father FHIR Text Text String Optional 0..*
Last Name (Family) Last name of Father FHIR Text Text String Optional 0..1
OR
Full Name
Full Name of Father (used where
First and Last names are not split
into separate fields in a system)
FHIR Text Text String Optional 0..1
H Address
H Father's Name
Newborn Delivery Health Interaction (DEFINITIONS) - LOGICAL MODELNOTES / VERSION NO: 19/10 - 0.6
H Baby's Name
H Mother's Name
Queensland Clinical Terminology Service (QCTS)
VisionTo provide a lasting and effective solution for the management and meaningful use of up-to-date coding system reference data as well as associated artefacts (such as value sets and concept maps) which meets Queensland Health’s business and clinical needs.
Use of HL7 Fast Healthcare Interoperability Resources (FHIR)• Introduction of
– ValueSet, ConceptMap, and CodeSystem FHIR resources to represent local terminology subsets, maps, and coding systems respectively.
– Terminology server applications exposing the HL7 FHIR Terminology Service API for application integration
• Adoption of:– FHIR R4
– The Australian Digital Health Agency’s National Clinical Terminology Service (NCTS) FHIR specifications for content types and Conformant Server Applications
– The AEHRC Ontoserver syndicating terminology server
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Queensland Clinical Terminology Service (QCTS)
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Solution Overview
The Clinical Genomics Order Cycle
Clinical system(EHR)
Lab order(LIMS)
BioinformaticsVariant
Interpretation
Lab report
start
WhoCSIRO AEHRCHL7, LOINC, SNOMEDGA4GH
What
Clinical system(EHR)
Lab order(LIMS)
BioinformaticsVariant
Interpretation
Lab report
• LOTS and LOTS of code systems in the genomic space – bringing them into official FHIR code systems and implementing into Ontoserver etc
Clinical system(EHR)
Lab order(LIMS)
BioinformaticsVariant
Interpretation
Lab report
WhoCSIRO AEHRCQGHAGenomics England
What
• Smart on FHIR clinical tools hooked into EHRs
• Genomics England has an ordering system that uses FHIR data models internally
• Phenopackets work to ensure pedigree etc can align against a FHIR data model
Clinical system(EHR)
Lab order(LIMS)
BioinformaticsVariant
Interpretation
Lab report
WhoMelbourne Genomics
What• GenoVic uses FHIR as its API at
the boundaries – and for internal data models
• consent codes and representation to standardise encoding of genomic consent forms (very much WIP)
WhoHL7 FHIR WG (international)
What
Clinical system(EHR)
Lab order(LIMS)
BioinformaticsVariant
Interpretation
Lab report
• aligning representation of variants to match thinking in GA4GH
• existing standards are the kings here (VCF, BAM) despite certain limitations
WhoHL7 FHIR WG (international)
What
Clinical system(EHR)
Lab order(LIMS)
BioinformaticsVariant
Interpretation
Lab report
• DiagnosticReport profiles to report back genomic results in standardised discrete units –across various genomic domain (cancer v rare disease etc)
• In Australia – currently more likely PDF
Existing Specifications Harmonised ContentPrimary Care Data
Dictionary FHIR Implementation Guide
Primary Care, Standards Data Specifications, Data Sets, KPIs, Assessments, FHIR, OpenEHR
Identification of all the existing specifications in Primary Care that would inform the development of the core data requirements.
Initial meeting of stakeholders to identify all potential data inputs, use cases and priorities for the projects.
Community established with clinical and technical working groups.Use case agreed- reusable core data set, associated SNOMED CT Value Sets and a FHIR IG to exchange.
Harmonised clinical data items and identification of core common items
Candidate core data elements which are common to multiple existing specifications, that enable structured data recording and data reuse.
Clinical Content and Technical Working Groups consensus on the core data items to be defined and included in a data dictionary and identification of the first use cases to exchange these core data items.
Outputs progressively developed and iterated through a series of face to face workshops (4) and webconferences (5)
Primary Care clinical information model
Release 1 of the Data Dictionary defines the core common data elements to enable quality use of information as well as enable the safe and meaningful exchange of information to other care providers. The Dictionary includes: meta data, definitions and recommended terminology bindings
Enter once, multiple use and interoperable exchange and reuse
Community, consensus based development process with multidisciplinary clinical content and technical working group.
Endorsement proposed to be progressed through clinical colleges and professional groups.
FHIR IG- Primary Care Au Practice to Practice Record Exchange
An industry agreed specification, informed by the Primary Care Data Dictionary Core Common Model for the exchange of an individuals record when they request a transfer of their records from their current practice to a
new practice.
FHIR IG profiles based on the HL7au Base resources, progressively developed and tested through a Community process.
Endorsement proposed to be progressed through HL7au
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Primary Care Data Quality P2P
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