Healthcare on FHIR: A Review of HL7’s Hottest Healthcare Technology Standard

Fast Healthcare Interoperability Resources (FHIR) represents an exciting new direction for healthcare interoperability where modern lightweight protocols are used to tame the complex myriad of data and systems that undergird large hospital systems and healthcare information exchanges.

From the HL7 FHIR Overview: “FHIR aims to simplify implementation without sacrificing information integrity. It leverages existing logical and theoretical models to provide a consistent, easy to implement, and rigorous mechanism for exchanging data between healthcare applications.”

With well over 100 Resources currently defined and the adoption of a robust and consistent RESTful communication strategy, FHIR offers the hope of a brighter future where patients, clinicians, and all other stakeholders interact with healthcare information through an ecosystem of mobile, web-based and traditional applications and services.

SMART (Substitutable Medical Apps, Reusable Technology) on FHIR, takes matters even a step further standardizing the authentication, authorization, patient consent and application container and launch strategy allowing healthcare app developers to create and publish powerful modern applications that can be selected from app stores and launched on any number of SMART health information systems.

Sheila Connelly, MS, PMP, is an HL7 Interface Analyst with Optum Technology and will lead a presentation that introduces attendees to the HL7 FHIR standard and shares what she has learned about the quickly emerging field of FHIR technologies and FHIR-based apps.

Transcript

1. Healthcare Interop Boston is grateful! With many thanks for hosting us from…
2. Undergrad in Computer Science PMI PMP-certified hands on Technical Project Manager 20-year business owner offering software development and software documentation services (general corporate and finance) Changed focus mid-career to healthcare technology Master of Science in Health Informatics, Northeastern University Niche area of expertise in HL7® V2, V3, and FHIR® Standards and Interoperability Boosting healthcare data availability with HL7® V2, V3, and FHIR® standards. You? About Sheila Connelly
3. Healthcare on FHIR® 1. FHIR and Semantic Interoperability 2. FHIR in Action – Apple Health 3. Technologies 4. Kick Start Your FHIR Immersion 5. FHIR Profiles and Implementation Guide 6. Authoring Resources 7. 21st Century Cures Act 8. Where is FHIR on the Gartner Hype Cycle? A Review of the Hottest HL7® Healthcare Technology Standard
4. FIRST Standards and interoperability are my top interest in healthcare technology. You are here…must be one of yours too. THIRD You may see an opportunity for your own projects and get on board… if you are not already. Who’s not on board? SECOND You cannot have interoperability without standards… particularly those that allow for semantic interoperability Why ARE We Talking about Standards and Interoperability, Particularly FHIR® from HL7®?
5. • FHIR® is a standard used to exchange healthcare information electronically • FHIR enables semantically unambiguous interoperability • Disambiguation • allows healthcare data to be carried with exactly the same meaning throughout its journey in the healthcare data exchange and messaging world. • No one need change their underlying data structure to use FHIR. Why the Excitement?
6. Two steps are required to achieve semantic interoperability: 1) the ability to exchange information; and 2) the ability to use the information that has been exchanged. • unambiguous shared meaning; exact same understanding by both the sending and receiving applications Interoperability: Bi-directional What is Semantic Interoperability?
7. • Access data through FHIR APIs (application programming interface) • Do I need to know the data source’s specific data structure, platform, or physical infrastructure? Nope! • Do they need to know mine? Nope! • Am I scared? Maybe. The data source organization decides which of their data can be created, read, updated, deleted, searched. Org 1 Database Org 2 Database Org 3 Database My Database My App How is Data Accessed? Interoperability is bi-directional exchange; data must be able to go back and forth. Read-only is a great start, we need full CRUD operations. Through a FHIR API of course!
8. in Action! • Let’s see FHIR working for real! • Apple Health Records • Aggregation works for airlines, hotels, movies, finance, banking – why not healthcare data too? • Growing patient demand • e-Patient Dave (epatientdave.com) • Gimme My DaM Data – Data about Me! • Let patients help!
9. Did you know? Your iPhone comes with a Health app
10. Apple Health Records On January 24, 2018, Apple announced a new capability for its iPhone Health App.
11. NEW HEALTH APP SECTION: Health Records Consolidated medical data from multiple provider EHR systems.  Your provider must participate  You must consent  Data is encrypted in transit and at rest https://support.apple.com/en-us/HT208647
12. Let’s look inside…
13. HL7® FHIR® Source Data
14. Meet Amlan, my new best friend. Amlan told me that he manages the Epic API development team who built the APIs (to access Epic data) used with Apple Health Records. https://open.epic.com/interface/fhir
15. Argonaut Data Query Implementation Guide HL7® FHIR® SMART on FHIR > HealthKit > HKHealthStore EHR vendor-specific FHIR APIs these and more…
16. I define a set of data models and APIs to perform CRUD operations against the data obtained. I define an application’s environment and security. FHIR is not required to have anything to do with SMART, but SMART is popular and there are many SMART on FHIR apps. Applications using both are said to be: SMART on FHIR SMART = Sustainable Medical Applications & Reusable Technologies FHIR = Fast Healthcare Interoperability Resources
17. Both Smart and FHIR Embrace Common Web Standards OAuth2 REST API HTTPS JSON Atom XML REST API Open Specs OAuth2 HTML5 HTTPS FHIR Open ID Connect (OIDC) Turtle Open standards enable developers to build apps that can connect to health data systems such as EHRs and data warehouses without requiring specialized knowledge about each system.
18. Argonaut Data Query Implementation Guide http://www.fhir.org/guides/argonaut/r2/index.html Use Cases for Argonaut Project http://argonautwiki.hl7.org/images/e/ec/Argonaut_UseCasesV1-1.pdf
19. Learn more: https://open.epic.com/Tutorial
20. Wow! • There is a lot to learn. • How do I get started?
21. March 22, 2017 – FHIR Release 3 (STU) Published End of 2018 – FHIR Release 4 (Normative) – Rumor or Real?
22. FHIR R3: http://www.hl7.org/fhir Peek at FHIR R4: http://build.fhir.org • Start reading at the FHIR Home page • Read the Executive Summary and keep going Kick Start Your FHIR Immersion
23. SMART Developer Resources • Tutorials • Link to SMART sandbox • Link to App Gallery https://dev.smarthealthit.org
24. HL7® FHIR® for Specifiers Track HL7 FHIR DevDays, June 19-21, 2018, Boston Profile Implementation Guide Two Presentations: 1) FHIR Profiling Overview and Introduction Michel Rutten Firely, the Netherlands 2) Profiling Academy - Profiling Guidelines Marten Smits Firely, the Netherlands Two Presentations: 1) Implementation Guide Authoring Ardon Toonstra Firely, the Netherlands 2) Implementation Guide Tooling Ardon Toonstra Firely, the Netherlands Lloyd McKenzie Gevity Inc, Canada Rick Geimer Lantana, USA
25. The ImplementationGuide Resource includes Profiles, each of which are StructureDefinition Resources per Project All Profiles are defined with the StructureDefinition resource The ImplementationGuide resource includes far more than Profiles One Learn More: http://hl7.org/fhir/conformance-module.html
26. Spend Time With the StructureDefinition Resource Your new best friend in Profiling! Learn More: https://www.hl7.org/fhir/structuredefinition.html
27. Step-by-Step One foot in front of the other… Keep going…  Capture Use Case Requirements  Describe the Capabilities  Think Through Your Scenario  Which Resources? Core vs.Custom  How might you profile?  What might you profile?  Attend the Profiling Academy  Try Forge - FHIR Profile Editor  Search for Prior Profile Work  Look at Tools to Author Profiles  Spend Time With the StructureDefinition Resource  Start Profiling  Done? Time for the ImplementationGuide  Review the Implementation Guide Registry  Create an ImplementationGuide resource  Implementation Guide Authoring Tools
28. Capture Use Case Requirements • What types of data does your web and/or mobile app require? • Who? Actors – Provider, Patient • Which REST interactions? Only read and search? Or create and update as well? What about delete? • Which operations are supported? Is there anything special about operation behavior? • Security? http://www.fhir.org/guides/argonaut/r2/index.html Log all RESTful API usage – create, read, update, delete, search, history – in an AuditEvent resource Simple or Complex?
29. Describe the Capabilities Human-friendly content to describe the actual message or document exchange per the use case. Describes: • the capabilities of the software application • the actual implementation available at a specific access point • which resources are used • which operations are necessary • various setup configurations • requirements 29 Learn More: https://www.hl7.org/fhir/capabilitystatement.html http://www.fhir.org/guides/argonaut/r2/definitions.html CapabilityStatement Resource
30. Think Through Your Scenario Create a free ClinFHIR account: http://clinfhir.com Vimeo Demo and App created by David Hay: https://vimeo.com/231087067 Try ClinFHIR Scenario Builder to solidify your ideas.
31. Resources: Core vs.Custom • Which FHIR Resources did you include? • Which data elements within each Resource are required? • Extend a resource with additional data elements or in another way? • If yes, you need a Profile • If no, the resource is fine ‘as is’ • Constrain a resource by removing data elements or in another way? • If yes, you need a Profile • If no, the resource is fine ‘as is’ • Profiles adapt FHIR to specific use cases • Custom resources require profiling Learn More: http://hl7.org/fhir/resourcelist.html http://www.fhir.org/guides/argonaut/r2/profiles.html Clinical | Diagnostics | Medications | Administration | Terminology | Financial | more
32. How might you profile? • Profiles adapt FHIR to specific use cases • Profiling a resource includes: • Extend the resource by adding additional data elements? • Constrain the resource by removing data elements? • Change cardinality? Required vs. Optional? Not used? Only 1 or many? • Change terminology binding (strength and value set)? • Constrain a data type within the resource? Learn More: https://www.hl7.org/fhir/profiling.html Michel Rutten, Firely, the Netherlands Profiles Adapt FHIR to Specific Use Cases
33. What might you profile? • Profile what is to be used, not used, or extended • Required? Set minimum cardinality to 1 • Excluded? Set maximum cardinality to 0 • Not found in core? Build an extension • Coded Elements • Use standard codes – LOINC, SNOMED, RxNorm • Create your own local codes • Expected Behavior • Which interactions, operations, search parameters are supported? • Specific security details • Mapping to local requirements and alternative views of the data Learn More: http://hl7.org/fhir/profilelist.html | http://www.fhir.org/guides/argonaut/r2/StructureDefinition-argo-immunization.html Resource by Resource…
34. Attend the Profiling Academy • Online training for FHIR profiling • FREE • Best Practices • Modules • Movies • Learn!! Learn More: https://simplifier.net/guide/profilingacademy/modules Marten Smits, Firely, the Netherlands Build Your Skills and Knowledge
35. Try Forge – FHIR Profile Editor • Forge is an editor for creating and editing profiles using a graphical user-interface. • Create, edit and validate FHIR profiles, extensions and implementation guides. • Forge is the official HL7 editor for StructureDefinition resources • https://simplifier.net/forge Learn More: http://docs.simplifier.net/forge/forgeIntro.html Helps to identify and solidify the changes you need
36. Search for Prior Profile Work Now that you know what you want and need… • FHIR registry - what has been published • https://registry.fhir.org • Extension Registry: http://hl7.org/fhir/extensibility-registry.html • All extensions are defined under: http://hl7.org/fhir/StructureDefinition • The HL7 FHIR Registry uses Simplifier.net • A lot of projects going on, a lot to re-use, copy, look at other people's decisions • https://simplifier.net • https://simplifier.net/core-extensions • Ask around… • Participate in the Profiling streams on Zulip Chat: https://chat.fhir.org Search the FHIR Registry for prior work before creating your own profile
37. Look at Tools Used to Author Profiles • Forge: https://simplifier.net/forge • Create, edit and validate FHIR profiles • Lantana Trifolia Workbench: https://trifolia.lantanagroup.com • Author profiles and certain types of value sets • Simplifier.net: https://simplifier.net/features • Web-based • Validate example resources against profiles • Learn who is using your profiles/extensions • Usage - how popular are my profiles? • Official backend for https://registry.fhir.org Rick Geimer, Lantana, USA, Trifolia Workbench Cross-over and differing features; find your preference
38. Remember the StructureDefinition Resource? Your new best friend in Profiling! Learn More: https://www.hl7.org/fhir/structuredefinition.html
39. Start Profiling • Profiling refers to the act of applying constraints to Conformance Module Resources that were designed to accommodate 80% of systems • Your use case most likely requires edits (constraints and/or extensions) to existing Conformance Module resources (the 20% of 80/20 rule) • The profile is built, or defined, in a StructureDefinition resource (part of the Conformance Module) Learn More: http://hl7.org/fhir/structuredefinition.html International National Regional Local When you tailor resources to fit your use case, you have built a profile
40. Done? Time for the ImplementationGuide One ImplementationGuide for One Project Profiles are just one component of the ImplementationGuide resource
41. Create an ImplementationGuide resource • An ImplementationGuide resource is a document that describes how FHIR has been adapted to the use case – Scope! • It is comprised of one or more CapabilityStatement, StructureDefinition (Profile), ValueSets as well as a narrative explanation. • Includes any images, pictures, logos, attachments Learn More: http://hl7.org/fhir/implementationguide.html http://wiki.hl7.org/index.php?title=FHIR_IG_Framework http://implementationguidetemplate.azurewebsites.net/ Lloyd McKenzie, Gevity Inc, Canada People read part of the ImplementationGuide, and computers read part.
42. Review the Implementation Guide Registry • Look through previous work in the FHIR Implementation Guide registry https://fhir.org/guides/registry • The Registry includes: • Specification for US Core (base US national implementation guide) http://hl7.org/fhir/us/core/ • Quality Improvement Core (QICore) Implementation Guide http://hl7.org/fhir/us/qicore Get some ideas!
43. Implementation Guide Authoring Tools • FHIR IG Publishing tool • Generate rendered implementation guides which consume profiles and value sets • The official HL7 open source command line tool http://wiki.hl7.org/index.php?title=FHIR_IG_Publishing_tool http://hl7.org/fhir/downloads.html • FHIR IG Framework – Tour of IG Publisher http://wiki.hl7.org/index.php?title=FHIR_IG_Framework Learn More: http://wiki.hl7.org/index.php?title=FHIR_IG_Publishing_tool http://wiki.hl7.org/index.php?title=ImplementationGuide_Guidance Thankfully there are tools to help!
44. Implementation Guide Authoring Tools Simplifier.net IG • Supports authoring and publication http://docs.simplifier.net/simplifier/simplifie rIGeditor.html • Write the narrative, include your resources, more…click publish and it outputs the FHIR Resource: ImplementationGuide • Publish to Registry: https://registry.fhir.org • Acts as a registry where people can discover existing implementation guides, profiles and value sets, extensions; can author extensions as well Ardon Toonstra, Firely, the Netherlands Thankfully there are tools to help!
45. Interested? Just start somewhere! • Apple Developer HealthKit: https://developer.apple.com/documentation/healthkit • Apple HKHealthStore - the access point for all data managed by HealthKit: https://developer.apple.com/documentation/healthkit/hkhealths tore • Apple Technical Video: Accessing Health Records with HealthKit, Jun 4 2018: https://developer.apple.com/videos/play/wwdc2018/706 • HL7 Argonaut Data Query Implementation Guide Version 1.0.0 http://www.fhir.org/guides/argonaut/r2/index.html • HL7 Argonaut Project Charter: http://geekdoctor.blogspot.com/2014/12/the-argonaut-project- charter.html • HL7 Argonaut Project: http://argonautwiki.hl7.org/index.php?title=Main_Page • HL7 Argonaut Use Cases V1.1: http://argonautwiki.hl7.org/images/e/ec/Argonaut_UseCasesV1- 1.pdf • HL7 FHIR DSTU2: http://hl7.org/fhir/DSTU2/index.html • HL7 FHIR Foundation: http://www.fhir.org • HL7 FHIR Release 3 (STU) http://hl7.org/fhir/index.html • SMART an app platform for Healthcare: https://smarthealthit.org • SMART App Authorization Guide: http://docs.smarthealthit.org/authorization • SMART uses OAuth 2.0: https://oauth.net/2 EHR VENDORS • Vendor - Cerner FHIR: https://fhir.cerner.com, https://code.cerner.com/ • Vendor - Epic App Orchard: https://apporchard.epic.com/Gallery?id=579 • Vendor - Open Epic: https://open.epic.com/Interface/FHIR • And other EHR Vendors…
46. Technical Blogs I like… Dr. David Hay Hay on FHIR http://fhirblog.com/ “Self-appointed FHIR evangelist (some would say FHIR Fanatic)” Based in Auckland, New Zealand A company I really like is Firely (https://fire.ly) A few years ago I followed their Blog post to create a FHIR client with Visual Studio .NET. It was excellent! Highly recommend. https://blog.fire.ly/2015/05/10/make-your-first-fhir- client-within-one-hour Firely organizes the FHIR DevDays events. Based in Amsterdam, the Netherlands
47. FHIR DevDays 1. Search up each of the FHIR DevDays speakers Many people are blogging, teaching, and sharing on different aspects of FHIR: • Boston: https://www.fhirdevdays.com/boston/speakers/ • Amsterdam: https://www.fhirdevdays.com/amsterdam/speakers/ 2. Attend FHIR DevDays in Amsterdam, November 14-16, 2018
48. Will high cost be considered information blocking? 21st Century Cures Act (Sec. 4003) The ONC must: (1) convene stakeholders to develop or support a framework and agreement for the secure exchange of health information between networks, (2) provide for testing of the framework and agreement, and (3) publish a list of networks that adopt the agreement. HHS must establish an index of digital contact information for health professionals, health facilities, and others to encourage the exchange of health information. The bill replaces the Health IT Policy Committee and the Health IT Standards Committee with the Health IT Advisory Committee. The ONC must periodically convene the Health IT Advisory Committee to report on priority uses of health IT and standards and implementation specifications that support the use and exchange of electronic health information. (Sec. 4004) Developers of health IT and health care providers may be penalized for engaging in information blocking. The ONC must issue guidance on the secure exchange of electronic health information. Title IV: Delivery Sec 4003. Interoperability Sec 4004. Information blocking $
49. Barrier to Entry? • Pointing out a recent article: ONCinterop forum kicks off https://www.politico.com/newsletters/morning-ehealth/2018/08/06/onc-interop-forum-kicks-off-306709 • Two tidbits: • “According to one presentation at an NIH conference, Cerner and Epic are charging thousands of dollars to register apps, with additional fees depending on the app’s business model.” • “One family planning questionnaire app, according to the presenter’s math, would set clinics back $750,000 according to this model. What have you heard about pricing? Stay informed: Videos of the ONC’s 2nd Interoperability Forum Days 1 and 3 – August 6 and 8 2018 https://www.healthit.gov/news/events/oncs-2nd-interoperability-forum
50. FHIR and the Gartner Hype Cycle Source: https://www.gartner.com/en/research/methodologies/gartner-hype-cycle Grahame Grieve posted #FHIR and the Gartner Hype Cycle on Sep 4 2018 A guest post by Wes Rishel @wrishel, well known in FHIR circles, and conveniently, a former Gartner Analyst http://www.healthintersections.com.au/?p=2847 HIGHLIGHTS Widest adoption so far: o sidecar read-only apps for EHRs; many SMART on FHIR FHIR needs: o a labor pool of developers and technical people who focus on FHIR while there are other technologies and tools competing for their attention o a healthcare org (with 5% of country’s patients) using FHIR for mission-critical apps – who will get there first? o a common pool of server-apps and client-apps o attention paid to practicalities of selling and delivery o conformance testing – assurance that if you buy two interoperable products that they will, in fact, interoperate o A body of knowledge for risk assessment – what does it really take to interoperate with important FHIR servers or important EHR clients? Where is the disillusionment? o Wes places FHIR “pre-trough”
51. Scan to visit my profile. Thank you! I hope you learned something new. I’d love to connect with you.