Monthly Archives: June 2016

Furore DevDays: Premiere #FHIR meeting in Europe

I’ve just booked my flights for DevDays:

FHIR Developer Days is an event for implementers, whether new to FHIR or with previous experience, to test and develop their FHIR implementations in a collaborative environment. FHIR DevDays offers a chance to work with the specification surrounded by others doing the same thing, side by side with experts to answer any questions. The hackathon and educational tracks are divided into beginner and advanced tracks. The beginners track for the hackathon will feature a round table with tutorials and intensive coaching.

DevDays is the best FHIR event in Europe each year, and this year, the list of subjects, and the thought leaders, has grown again. Even if you’re not committed to FHIR, that’s an amazing group of people to engage with at a single meeting.

You should be there! I’ll see you there…

 

 

 

Question: Apple CareKit and #FHIR

Question:

I am very new to FHIR and now i am trying the find out equivalent resource for  Apple carekit data. I think i can use FHIR Careplan & Goal for the CareKit data. Is that right?

Answer:

I’ve not done any work with CareKit, but Apple suggested I talk to Seth Berkowitz at BIDMC, who says:

CareKit is a set of UI and database components that provide a framework to display careplans, collect patient generated data, provide insightful feedback to and from patients via their iOS phones.  By leveraging simple game mechanics and Apple’s design ethos, the UI components of CareKit help motivate patients to comply with their daily medications and activities as part of their care plan.  The assessment component streamlines the collection of subjective and objective data from patients using the phone as middleware. Objective data collection is facilitated through HealthKit, which is Apple’s centralized database on it’s phones that facilitates the sharing of objective health metrics in between apps.  The last component of carekit is a communication module that helps patients share their care plans and results with friends, family, and medical professionals

BIDMC we are integrating our CareKit app directly into our homebuilt EHR so that the app becomes a direct conduit of prescriptions and orders from doctor to patient, and patient generated data from patient to doctor.  Although our short term goal is to benefit our own population of patients, we share Apple’s long term vision of widely disseminating these engaging apps.  To that end, we are trying to leverage FHIR APIs as much as possible to serve as the connections between our EHR and the App.  The hope is that Apps like this serve as a “carrot” to promote more widespread adoption of the FHIR standard.  Our two main APIs using FHIR are a medication search bundle and CarePlan resource.  Our medication bundle leverages our institutions participation in the Argonaut projects

CareKit encompasses several functions which pose potential FHIR interfaces for data download and upload.  To date, my group has focused on leveraging FHIR for data download in order to populate the CareKit “CareCard” (a patient check list of careplan activities) and Carekit “Assessment” or subjective and objective measurements collected on the phone. An overarching question that we’ve been trying to solve is how encode UI / implementation specific data fields within the appropriate FHIR schema.  For example, a careplan activity in carekit is displayed with a title, a subtitle, and more detailed instructions.  For each careplan activity I’ve been using the following mapping

  • Title: activity.detail.code.text
  • Subtitle:  activity.detail.goal (either display or description of a contained resource)
  • Instructions: activity.detail.description

For quantitative measurements that are collected on the phone through the HealthKit database, I define an “observation” activity within the careplan.  The activity.detail.code.coding array defines a LOINC codable concept which is then mapped to Apple’s internal reference system for various physiological measurements (heart rate, blood pressure, daily sodium intake, etc)

Finally, we define certain alert conditions that may prompt a message to the patient after a measurement is obtained.  These alerts are implemented as an extension to the activity.detail.goal.  The extension includes a valueQuantity which is the threshold that triggers the alert and a referenced Flag resource which is the alert prompt to the user.

There’s much more to be done to build an end-to-end CareKit FHIR interface, but that’s what we’ve been working on so far.

Thanks to Seth and also to Pascal Pfiffner, who’s been a trail blazer with regard to FHIR use on iOS (and who maintains the FHIR Swift reference implementation).

Seth noted that with the careplan resource, it feels like they’re pushing the limits of how the careplan is being used in practice – and indeed, that’s true. There’s a lot of active projects using FHIR as the format for exchange underlying shared care/ collaborative care projects that involve the patient, and their various care teams: family, professional, social etc., and this is a new – exciting! – area where there’s not a lot of established knowledge, culture, and practice for us to fall back on. So implementers should expect more change in this area than in the well established ones (patient management, diagnostics, medication administration, billing).

Question: Binding choices

Question:

A question regarding “Standard” codes vs. Customized codes: To my understanding, if I want to exchange FHIR resource, any property in that resource can be filled by either of the following options:

  • Using the standard clinical coding system for relevant clinical properties (for example, SNOMED CT code for MedicationOrder>Medication>code
  • Using the HL7 FHIR administrative coding system for relevant administrative properties (for example, http://hl7.org/fhir/ValueSet/medication-order-status for MedicationOrder>Status)
  • Using customized, in-house, coding system, but for that I need to define it as appropriate ValueSet, bounded into appropriate Profile.

Answer:

So this answer (and the question, really) applies to any property in a resource that has a type of Coding or CodeableConcept. In principle, any property of a resource that has a type can be filled by any one of those choices – a SNOMED CT code (or RxNorm, or LOINC, or …), a FHIR defined code, or a locally defined code. However for all these properties, we ‘bind’ them to a value set, and that value set makes a rule about what kind of codes can be used.

Element <– (binding) –> ValueSet

So if the property is bound to SNOMED CT, then you have to use a code from SNOMED CT. But note that if the type is CodeableConcept, which can have more than 1 coding, then this means that one of the codings has to come from SNOMED CT – for the others, you have can use anything at all that you like.

Further, the binding itself has an important property – the ‘strength‘ of the binding. This key property tells you how to interpret the binding:

required You have to use one of the specified codes
extensible You have to use one of the specified codes, unless there isn’t an appropriate one. Then you can use whatever you like
preferred This is the sort of codes you should use – and this value set really is a good idea to use
example This is the sort of codes you should use

So the last 2 binding strengths are not, well, binding: you can ignore them as you see fit. So what you can actually use in a resource property depends on the strength of the binding, and the value set it references. But, sadly, most of the really interesting properties in most resources have a binding strength of ‘example’ – precisely because they are most interesting, we have no way to get consensus on the right coding system (let alone the right set of concepts). A great example is Condition.code:

. code 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Condition/Problem/Diagnosis Codes (Example)

An example binding to a large set of SNOMED CT codes….

Finally, some notes on your choices:

  • Standard clinical coding system: we always recommend that you use one of these. But these can be hard to use. We introduced the terminology service to make this easier, and this is a concept that’s just about in the goto-market phase
  • FHIR code systems are mostly defined for the fixed properties like status where you have to use one of the fixed codes we defined, but sometimes we define a code system to be used with Coding/CodeableConcept. We generally try pretty hard to not overlap with the standard terminologies, so it’s usually a choice of one or the other
  • When you use a customised in house coding system, you don’t actually have to define it using a value set, but doing so allows you to tell everyone else in a computable fashion what you are doing, so it’s a good idea, yes.

 

 

Question: How do profiles fit into the overall conformance picture

Question:

How are Conformance Resource and Implementation Guide (IG) resources are linked? I understand usage of both but how both will be linked to create Profiling.  Not clear about using both of them, what scenario or use case would be that?

Answer:

Well the conformance resource includes server capability or client desire for server capability and also includes what all actual Resources are supported, and links to what profiles are (or should be) supported on the system. So the conformance statement ‘creates’ profiling by making it clear what profiles the system supports.

ImplementationGuide is a primarily a publishing thing – publishing a group of conformance statements and profiles, with their supporting value sets etc, in a single logical group, with a single identifier.  The implementation guide may – and commonly does, but not always – include one of more conformance statements as examples, or requirements. So it ‘creates’ profiling by allowing for publication of  group of conformance statements and profiles. So it’s primary function is to establish logical groups of profiles.

Most uses of Implementation Guide will be publishing national standards, or project agreements (projects such as argonaut) rather than server level publishing.