Introduction to

FHIR

Grahame Grieve
July 10, 2014

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 This presentation

 Is licensed for use under the Creative

Commons, specifically:
 Creative Commons Attribution 3.0 Unported
License
 (Do with it as you wish, so long as you give credit)

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 The “FHIR” Acronym

 F – Fast (to design & to implement)

 H – Health
 I – Interoperable
 R – Resources (Building blocks)
 There is more on Resources to follow
 “Fast” is relative – no technology can make
integration as fast as we’d like
 “FHIR” (pronouced “Fire”) is a fertile source of
puns etc. Feel free to make your own
3

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 What is FHIR?

 A set of modular components called

“Resources”
 Resources refer to each other using URLs
 Build a web to support healthcare process
 Exchange resources between systems
 Using a RESTful API (e.g. web approach)
 As a bundle of resources (messages, documents)

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 Genesis of FHIR

 There has been a need to share healthcare

information electronically for a long time
 HL7 v2 is over 25 years old
 Increasing pressure to broaden scope of
sharing
 Across organizations, disciplines, even borders
 Mobile & cloud-based applications
 Faster – integration in days or weeks, not months
or years
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 Genesis of FHIR

 HL7 did no have much to offer in this space?

 V2 Old, and limited by it’s own rules
 V3 too slow and too hard
 CDA has success, but both limited and too hard
 Different contexts of interoperability  different
representations that aren’t compatible
 Nothing suitable for light-weight integration,
or for Health 2.0
 No other Organization so well situated
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 Genesis of FHIR

 HL7 undertook a “Fresh look”

 What would healthcare exchange look like if we
started from scratch using modern approaches?
 Web search for success markers led to
RESTful based APIs
 An exemplar: Highrise from “37 Signals)
 Drafted a healthcare exchange API based
on this approach
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 FHIR Development
Progress
 July 2011 – Conception
 Aug/Sept 2012 – First Draft Ballot
 Sept 2012 – First Connectathon
 Aug/Sept 2013 (now) – First DSTU ballot
DSTU = Draft Standard For Trial Use
 January 2014 – DSTU finalised
 ~June 2015 – 2nd DSTU
 Late 2016? – Normative Version

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 FHIR PRINCIPLES

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 FHIR Manifesto

 Focus on Implementers
 Target support for common scenarios
 Leverage cross-industry web technologies
 Require human readability as base level of
interoperability
 Make content freely available
 Support multiple paradigms & architectures
 Demonstrate best practice governance
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 Implementer Focus

 Specification is written for one target audience:

implementers
 Rationale, modeling approaches, etc. kept elsewhere

Multiple reference implementations from day 1 using HL7.Fhir.Instance.Model;

 using HL7.Fhir.Instance.Parsers;
using HL7.Fhir.Instance.Support;

XmlReader xr = XmlReader.Create(
 Publicly available test servers new StreamRead
IFhirReader r = new XmlFhirReader

// JsonTextReader jr = new JsonTe

 Starter APIs published with spec // new StreamRead

// IFhirReader r = new JsonFhirRe

 C#, Java, Pascal, ObjectiveC – more to come

ErrorList errors = new ErrorList(
LabReport rep = (LabReport)Resour
Assert.IsTrue(errors.Count() == 0

 Connectathons to verify specification approaches

 Instances you can read and understand
 Lots of validated examples
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 Support “Common”
Scenarios
 Focus on scenarios implementers ask for
 Inclusion of content in core specification is
based on core content rule
 “We only include data elements if we are confident
that most normal implementations using that
resource will make use of the element”
 Other content in extensions (more on this later)
 Easy to say, governance challenge to achieve
 Resources are simple and easy to
12
understand and use
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 Web technologies

 Instances shared using XML & JSON

 Collections represented using ATOM
 Same technology that gives you your daily news
summary
 Out-of-the-box publish/subscribe
 Web calls work the same way they do for
Facebook & Twitter
 Rely on HTTPS, OAuth, etc. for security
functions
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 Human Readable

 Clinical Documents have both narrative and

data
 The data / narrative dynamic exists
throughout the process
 In FHIR, every resource has a
human-readable expression
 Can be direct rendering or human entered

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 Freely available

 Unencumbered – free for use, no

membership required
 http://hl7.org/fhir

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 FHIR is Better

 Easy & Quick to understand & implement

 Code & example servers already exist
 Specification is free for use with no
restrictions
 Based on the Web
 Can be extended and adapted seamlessly
for local usage

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 FHIR & Cost of
Integration
 These factors will drive down the cost of
integration and interoperability
 Easier to Develop
 Easier to Troubleshoot
 Easier to Leverage in production
 More people to do the work (less expensive
consultants)
 Competing approaches will have to match the
cost, or disappear – effect is already being felt

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 Future impact of FHIR

 Impact of FHIR on the market:

 Drive interoperability prices down
 Higher Expectations
 Increased spend on integration (N x 2!)
 Overall Market focus
 PHR on the web
 Healthcare repositories (MHD+)
 Device Data management
 Retooling existing connections (will happen slowly)
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 ABOUT REST AND
RESOURCES

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 REST

 “Representational state transfer” – an

architecture for how to connect systems

 Outcomes
 Simple stable interfaces
 High Performance / Scalability
 Visible Process (e.g. can debug)
 Portability
 Reliability (resistance to failure)
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 REST in practice

 “Resources” with an explicit and stable URI

 The name for what gets exchanged in REST
 Defined behaviour and meaning
 Known identity / location
 Quite an abstract idea
 Formats: XML / JSON (+RDF, coming)
 Exchange using HTTP (Security: SSL / Oauth)
 Often “REST” is followed loosely, hence
“RESTful”
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 REST Operations
REST is based on CRUD(E):
 Create – create a new instance of data
 Read – get the content (state) of an
instance of data
 Update – change the content of an
instance of data
 Delete – remove the instance of data
 Execute – get the instance of data (?) to do
something for you
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 RPC vs REST

 RPC (Remote Procedure Call):

 Ask a server to perform some operation
 Hand it a set of parameters
 Server performs some operations
 Returns a set of parameters
 REST:
 Define a URI that represents the state of
something
 Tell the server what the state should be
2  Server makes the state change happen
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 RPC vs REST example

 Example:
 A device that monitors a patient %02 Sat
 Raises an alarm on EHR if it’s too low
 EHR can turn the alarm off
 RPC:
 POST http://acme.org/devices/turnOffAlarm
 Parameters: device id, alarm id
 REST:
 POST http://acme.org/devices/[deviceid]/[alarmid]
 Content: data to say “Alarm is off”
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 RPC vs REST

 Difference is subtle, and depends on

perspective
 Outcome is large difference
 REST is increasingly preferred in practice
 Most systems mix and match
 “mini-operations”
 General issue: REST doesn’t deal well if
server needs context from the client
 e.g. who keeps audit trail for the user’s context?
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 Paradigms

 FHIR supports 4 interoperability paradigms

RESTful Documents

Messages Services

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 Documents

 Similar to CDA
 Collection of resources bound together
 Root is a “Composition” resource Documents

 Just like CDA header

 Sent as an ATOM feed
 One context
 Can be signed, authenticated, etc.

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 Messages

 Similar to v2 and v3 messaging

 Also a collection of resources as an ATOM
feed
 Allows request/response behavior with
bundles for both request and response
 Event-driven
 E.g. Send lab order, get back result Messages

 Can be asynchronous
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 Service Oriented
Architecture (SOA)
 Do whatever you like
 (based on SOA principles)
Services
 Ultra complex workflows
 Ultra simple workflows
 Individual resources or collections (in Atom or
other formats)
 Use HTTP or use something else
 Only constraint is that you’re passing around FHIR
resources in some shape or manner
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 Paradigms

 Regardless of paradigm the content is the same

 This means it’s straight-forward to share content
across paradigms
 E.g. Receive a lab result in a message. Package
it in a discharge summary document
 It also means constraints can be shared across
paradigms
 E.g. Define a profile for Blood Pressure and use it
on resources in messages, documents, REST and
services
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 FHIR RESOURCES

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 Resources

 “Resources” are:
 Small logically discrete units of exchange
 Defined behaviour and meaning
 Known identity / location
 Smallest unit of transaction
 “of interest” to healthcare

 V2: Sort of like Segments

 V3: Sort of like CMETs
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 What’s a Resource?

Examples Non-examples
 Administrative  Gender
 Patient, Practitioner,  Too small
Organization, Location,  Electronic Health Record
Coverage, Invoice
 Too big
 Clinical Concepts
 Blood Pressure
 Allergy, Condition, Family
History, Care Plan  Too specific

 Infrastructure  Intervention
 Document, Message,  Too broad
Profile, Conformance

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Goal: 100-150 total
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 DSTU Resource List

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 Resource anatomy

 Resources have 3 parts

Extensions

Narrative

Defined
Structured
Data

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36

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 Resource Documentation
For each Resource, the specification provides:
 Scope and Usage Notes
 Resource Content (as UML and XML)
 Terminology Bindings (what codes can you use?
 Constraints (technical rules about usage)
 Discussion of Implementation Issues
 Search Parameters for RESTful interface
 Examples, Profiles, Formal Definitions
 Mappings to RIM, CDA, v2, etc
3
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 Example Resource
Definitions : UML

3
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39

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 Resource elements

 Resources are defined as an XML structure

based on desired wire syntax
 Hierarchy of elements
 Each element has
 Name
 Either a datatype or nested elements
 Cardinality
• All collections are nested in a containing element
 Definition
 Mappings
 But instances in XML or JSON

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 It’s all about the
resources . . .

Location

Lab
Related Patient

Person Report

Practitioner

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 References between
resources

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 Rules for references

 References can be relative or absolute

 References don’t have to be to the same
server
 Server does not have to enforce integrity
 Clients need to cater for broken links
 Targets can be ‘contained’ in the resource:
<Procedure xmlns="http://hl7.org/fhir">
<contained>
<Patient id="pat">
</Patient>
</contained>
<subject>
<reference value="#pat"/>
</subject>
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 Data types

 Based on w3c schema and ISO data types

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 Data types (cont’d)

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 CodeableConcept

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 Vocabulary

 Support for coded data of varying complexity

 Some codes defined as part of resource,
others referenced from external vocabularies
 LOINC, SNOMED, UCUM, etc.
 Recognition some will differ by
implementation space
 Can use Value Set resource to define more
complex code lists
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 Bundles

 When more than one resource needed

 Query result
 Document
 Message
 Atom ‘feed’
 Widely used on the web for syndicating data
 FHIR defines a JSON representation

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 Narrative

 All resources carry an html representation of their

content
 It’s a clinical safety issue
 The receiver has a fall back option if the system is not sure it
fully understands the content
 It is not mandatory, but SHOULD be present
 In a closed eco-system, with extremely tight control and
strong conformance testing, it may not be necessary
 But things often change over time
 So using narrative is highly recommended
 Saves a lot of money downstream from the author

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 Narrative XHTML

 Narrative is XHTML. Formatting allowed:

 Tables, lists, divs, spans
 Bold, Italics, styles etc
 E.g. all static content
 Features not allowed:
 Objects, scripts, forms – any active content
 Links, Stylesheets, iframes – web context
 Local storage, Microdata (no active content)
 Concerns are security and clinical safety
5
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 FHIR EXTENSIONS

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 The Case for Extensions

 Extensions are often problematic in existing

HL7 specs
 Z-segments in v2
 What does this mean?
• ZSB|20080117|Q^57|4.30^uL
 Foreign namespaces in CDA/V3
 Break schemas
 Simple choice – design for absolutely
everything or allow extensions
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 Extensions

 FHIR has a standard framework for

extensions
 Every FHIR element can be extended
 Every extension has:
 Reference to a computable definition
 Value – from a set of known types
 Every system can read, write, store and
exchange all legal extensions
5
 All extensions are valid by schema etc
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 Extensions without the
pain…

 Extensions are built into the wire format

 All conformant systems can “handle” any possible

extension - Just a bucket of “other stuff”

 Extensions rendered in human readable portion

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 Governing Extensions

 Extensions are not a silver bullet

 FHIR has a sliding scale governance for
extensions
 Local Projects
 Domain standards (e.g Best Practice
Cardiology)
 National Standards (e.g. Standard Finnish
Extensions)
 HL7 published extensions (corner cases with
international scope)
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 What’s the goal here?

 In most areas of healthcare standards, there is

wide variability
 Between systems, countries, institutions, clinicians
 Choices:
 Specification only supports core – no one can use it
 Specification adds everything – no one understands it
 Specification picks winners – they can use it
 Allow extensions that people can use
 Extensions tame the specification

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 Example Extension

Eye Colour to patient resource:

 Need to pick a URL
 Need to choose a type
 Have to declare and publish the extension
(at the URL)
<Patient xmlns="http://hl7.org/fhir">
<extension url="http://acme.org/fhir/patient#eyecolor">
<valueCode value="brown"/>
</extension>
…
5
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 Publishing an Extension
Field Value
Context The patient resource
Name Eye Colour
Definition Eye Colour as chosen by clerical staff based
on visual inspection
Requirements Refer to policy 23B section A.1.2.3
Cardinality 0..1
Type String
Binding Codes: blue, brown, green, mixed, violet
Modifier false
Constraints
Mappings .
5
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 FHIR OPERATIONS

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 Business Operations
 Register a patient:
 Create a Patient Resource
 Admit a patient:
 Create an Encounter Resource
 Move a patient from one bed to another
 Find and update the encounter resource
 Prepare a list of medications to
administer
 Search through the medication prescriptions
6 for a patient (and then apply logic)
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 FHIR Resource URLs

Template Description Example

[base] Server URL http://fhir.com

[base]/[type] URL for type http://fhir.com/Patient

manager

[base]/[type]/[id URL for a resource http://fhir.com/Patient/23

]

[base]/[type]/[id URL for a past http://fhir.com/Patient/23/_hist

roy/2
]/_history/[vid] version of a
resource
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 Operations / Instance

Op Description Request Response

Content Content

read Read the current state of the -- Resource

resource
vread Read the state of a specific version -- Resource
of the resource (e.g. what it was in
the past)
update Update an existing resource by its id Resource --
(or create it if it is new). Use the
resource representation supplied
delete Remove the resource so it is no -- --
longer present (note: it still has a
history)
6 history Get a list of all the past versions of -- Atom feed
theunder
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 Operations / Type

Op Description Request Respons

Content e
Content
create Create a new resource with a Resourc --
e
server assigned id
search Search through all resources of Params Atom
Feed
the type based on some filter
criteria
history Get a list of all the past versions -- Atom
Feed
of this resource type

validat Check that the content would be Resourc Resourc

e e
e acceptable as an update
(Operatio
nOutcom
6 e)
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 Operations / System
Op Description Request Response
Content Content

conformanc Get a conformance statement -- Resource

e for the system
transaction Update, create or delete a set of Atom Atom
Feed Feed
resources as a single
transaction
history Retrieve the update history for -- Atom
Feed
all resources (full pub/sub)

search Search through all resources of Params Atom

Feeds
all types based on some filter
criteria

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 PROFILES &
CONFORMANCE

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 Conformance Resources

 Conformance – a state of system capabilities

 Profile – a set of rules about a resource is
used
 Value set – describes a set of codes that can
be used for something

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 Conformance

 A resource for documenting conformance to

FHIR
 Can be used for:
 Stating how a specific system instance behaves
 Defining how a software system is capable of behaving
(including configuration options)
 Identifying a desired set of behavior (e.g. RFP)
 To declare itself “FHIR Conformant”, a server
must publish a Conformance instance
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 Profiles

 Document constraints and extensions on

one or more resources
 May also define new extensions search
terms, new messaging events, etc.
 Subsumes: template, implementation profile,
DCM (Detailed Clinical Model), etc.
 Looks an awful lot like the definition of the
resources themselves
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 You can download profile XML for all resources
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 Using Profiles

 You can just go ahead and use a resource

 No need for a profile
 But you can write a profile
 Document your usage in detail for partners
 You can mark a resource with a profile
 It’s just a claim – can test conformance with that
 Denormalization for performance

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 IMPLEMENTING FHIR

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 Where can FHIR be
used?
 Classic in-institution interoperability
 Back-end e-business systems (e.g. financial)
 Regional Health Information Organizations
(RHIO)
 National EHR systems
 Social Web (Health) Initial
 Mobile Applications Focus

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 Architecture Options

 Standalone FHIR Server

 A FHIR Server in front of an existing application (e.g.
SQL)
 FHIR as front end to an XDS server (“MHD”)
 An interface engine that ‘speaks’ FHIR
 A tablet/mobile phone application
 Web portal uses FHIR to access other systems
 A healthcare application that access information from
multiple systems as well as it’s own server
 Smart-On-FHIR – an EHR plug-in framework

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 Implementation
Assistance
 Reference Implementations – object
models, parsers, serializers, clients,
validators, utilities
 Schema, Schematron, Validation Pack
 1000’s of examples
 Live Servers to test against
 http://wiki.hl7.org/index.php?title=Publicly_Available_FHIR_Servers_for_test
ing

 Connectathons
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 Servers

 Use the servers to explore how it works

 Write clients that use the test data
 Test that you got your own system right
 Most developers:
 use the servers to learn
 consult the documentation occasionally
 (we do recommend to read the specification at
least a little)

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 Other Free software

 See
http://wiki.hl7.org/index.php?title=Open_Source_FHIR_implementations

 Coming shortly:
 “Sprinkler” – a conformance test tool for
servers
 “Forge” – an editor for conformance
statements
 A Value set Editor
 Several implementation guide publishers
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 Connectathons

 Open invitation to any interested party to come

and write software that exchanges FHIR
resources
 Always hold one before HL7 meetings (last
week) + Others by invitation
 Mix of skills
 Newbies (“where is the spec?”)
 Old hands who’ve been to every connectathon
 Experiment with new features
 We have a virtual connectathon all the time…
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 Implementation
Assistance
 Stack Overflow – ask implementation questions
 Link from front page

 Search for answers first

 Don’t ask for changes to the spec (get deleted!)

 gForge Tracker – ask for changes to the spec

 Link from bottom of every page

 But have discussion somewhere first

 Disqus – on every page of the specification

 Skype – implementers channel – 105 participants
 FHIR Email list, Connectathons, Tutorials
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 Migration

 No expectation that people will migrate

existing interfaces any time soon.
 Initial adopters are expected to be green-
field, new technology
 FHIR may see use behind the scenes in v2
systems before it sees use over the wire
 Forthcoming policy initiatives may
necessitate revisiting existing interfaces

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 Migration – v2

 Already have an integration engine that

supports translation between v2 and FHIR
 Resources map to segments reasonably well
 As always, the challenge with v2 mapping is
the variability of v2 interfaces
 “Common” mappings can be created, but they
won’t be one size fits all

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 Migration – CDA

 Made more complex by human-readable

nature
 Need to ensure text <-> entry linkages are
retained
 Will best be handled on a template by
template basis
 Likely start with important ones like C-CDA

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 FHIR Manifesto

 Focus on Implementers
 Target support for common scenarios
 Leverage cross-industry web technologies
 Require human readability as base level of
interoperability
 Make content freely available
 Support multiple paradigms & architectures
 Demonstrate best practice governance
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 Thank you

 FHIR:
http://hl7.org/fhir
 Development team wiki home:
http://wiki.hl7.org/index.php?title=FHIR
 Twitter:
https://twitter.com/search?q=%23FHIR
 Stack Overflow:
http://stackoverflow.com/questions/tagged/hl7-fhir
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