Thursday, March 27, 2014

Why FHIR is so cool - also for clinical research

Last week I took an "HL7 FHIR" course under the motto "life long learning".
I became enthusiastic about FHIR as it takes away many of my concerns about HL7-CDA.

FHIR (pronounce "fire") has been developed by software people, so by "ordinary" IT people, and in such a way that it can be used by people like you and me without needing to learn every detail of the HL7-v3 RIM.
I have been teaching HL7-CDA at companies, and am teaching CDA at the university. It is extremely hard to explain. When doing so I get questions like "why is a medication an Act?" or even worse "why is a medication an observation?", or "why is a document an Act - that simply cannot be true".

When using FHIR however, you do not need to know about the RIM, acts and observations or roles and entities. In FHIR a medication is called a "Medication" - that's it! Furthermore FHIR is about RESTful web services, which is a modern way of exchanging information. Furthermore, FHIR is about snippets of information (named "resources") and not necessarily about complete documents.

Why is this also so important for clinical research?

When an investigator for example wants to know about all the medications that were subscribed to a subject in the last five years by different healthcare providers, he can either query all these systems which have different interfaces (I suppose here he is allowed to do so and has access), or ask these systems to generate a standardized document like a CCD or CCDA in the USA, or an "Arztbrief" or "Entlassungsbrief" in Austria (which is a kind of discharge letter). All these are "documents", meaning that one first need to find the right section in the document (probably by OID), and then inspect the "code" and "codeSystem" to be sure the entry is really about a medication, and then extract the information. As a medication is just an "observation", this is not very easy to automate.
Also, will a hospital be willing to generate a CCD either "on the fly" or in "off line mode" for a medication that was prescribed 5 years ago? And will it want to reveal information about the patient that is needed to make the document valid, but has nothing to do with the request?

When using FHIR, a medication is a "Medication" and the investigator can query the systems where the subject has records using a RESTful web service and a standardized FHIR interface, returning snippets of information (FHIR resources) instead of a whole document. So only the relevant information is provided.

Also for the patients themselves, FHIR is or will be a huge improvement. For example, if a patient wants to make a plot of all his/her cholesterol values of the last years as function of time, he cannot easily do so from a set of CDA documents, as CDA was never developed for such a use case. He/she will probably need to copy-past the values from the CDA document (or from the HTML view of it) into an Excel worksheet or other application, and then try to generate the plot.
With FHIR, the patient just can use a tool that uses a RESTful web service to query the system with the LOINC code of the cholesterol test (or tests), and get a list of values back with the test dates. Making the plot from this list is then probably a piece of cake (generic software for patients can become available).

So if FHIR with its web services is made available for use by patients, it could also be used for clinical research (of course only with authorization of the subject). Getting all the medications of the last five years would then become much easier as it is now by extraction from CDA documents (which were never designed for such a purpose), if the latter can be obtained from the different providers at all.

Your comments are very welcome as usual!