HL7Austria2015 Einsteiger

Catching FHIR
HL7 FHIR
Hands-on Training Course
Ewout Kramer
March 2015
© 2012 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Who am I?
 Name: Ewout Kramer

 Company: Furore, Amsterdam
 Background:
 FHIR core team, RIMBAA
 Software developer & healthcare
architect
 Contact:
 e.kramer@furore.com
 www.thefhirplace.com
Program
 Introduction to FHIR
 The Resource and REST
 Exercise - Requesting a Patient resource
 Deconstructing the FHIR data model
 Exercise - Editing a Resource Instance
 Bundles
 Simple search and search demo
INTRODUCTION TO FHIR
The Acronym
Relative – No technology can make integration as fast as we’d like
That’s why we’re here
Building blocks – more on these to follow
FHIR Manifesto
 Focus on implementers
 Keep common scenarios simple
 Leverage existing technologies
 Provide human readability
 Make content freely available
 Demonstrate best practice governance
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
 Delphi, C#, Java – 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 examples (and they’re valid too)
WHAT’S IN THE BOX?
Resources
Patient Prescription
The 80/20 rule
 Design for the 80%, not 100%

 Only include data elements in the artifacts if 80%
of all implementers of that artifact will use the data
element
 Allow easy extension for the remaining 20%
of elements
 which often make up 80% of current specs
 Vocabulary approach to extension definition
Extensibility
+ =
The Case for Extensions
 Simple choice – design for absolutely

everything or allow extensions
 Everyone needs extensions, everyone
hates them
 Define, publish, find extensions
 Repository
 Documented just like resources
 Can be fetched & interpreted by clients
Transport
HTTP/1.1 200 OK
Content-Type: application/json;charset=utf-8
Content-Length: 627
Content-Location: /fhir/Patient/1/history/1
Last-Modified: Sat, 03 May 2014 16:28:55 GMT
{"resourceType":"Patient","identifier":[{"use":"usu
al","label":"MRN","system":"urn:oid:1.2.36.146.59
5.217.0.1","value":"12345","period":{"start":"2001-
Just follow the industry...
 Exchanges use XML & JSON

 Collections represented using ATOM
 Same technology that gives you your daily news
summary
 Out-of-the-box publish/subscribe
 Support for REST: Web calls work the same
way they do for Facebook & Twitter
 Rely on HTTPS, OAuth, etc. for security
functions
Paradigms
 FHIR supports 4 interoperability paradigms
REST Documents
Messages Services
Regardless of paradigm
the content is the same
Receive a lab result in a message…
FHIR Message FHIR

Repository FHIR Document
Lab System
National
Exchange
…Package it in a discharge summary document
Looking at FHIR Resources from a software engineering perspective
DESIGN OF THE
RESOURCE
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
What is/isn’t a Resource?
Examples Non-examples
 Administrative  Gender
 Patient, Location,  Too small
Encounter, Organization,  Blood Pressure
 Clinical Concepts  Too specific
 AllergyIntolerance,  Pregnancy
Questionnaire, Observation
 Too broad
 Infrastructure
 Electronic Health Record
 Document, Message,
Profile, Conformance  Too big
Structure of a Resource
Metadata
Narrative
Resource
Elements
Extensions Extensions
Structure of a Resource
(XML example)
Human Readable
 CDA taught HL7 a very important lesson

 Even if the computers don’t understand 99% of
what you’re sending, that’s ok if they can properly
render it to a human clinician
 This doesn’t just hold for documents –
important for messages, services, etc.
 In FHIR, every resource is required to
have a human-readable expression
 Can be direct rendering or human entered
Resources in the spec
Let’s take a look at some Resources in

the specification….
Composition vs. reference
 FHIR makes composition and references

explicit:
 References are in between Resources. No
context conduction across references – safe
retrieval as individual resources.
 Composition is within a Resource: Components
have no meaning outside resource, no identity, no
separate access path except through resource
Composition of a Resource
Resource Root
Resource Component
Simple & Complex

elements (may be
repeating)
Composition
Diagnostic
Patient
Report
Practitioner
Observation
Resource Reference
Example: part of DiagnosticReport
http://fhirblog.com/2014/01/24/modelling-
encounters-with-fhir/
Not a hierarchy!
Not an “electronic” version of a patient file…
Patient
Episode Episode
Visit Visit
Observation Order
A Resource’s identity
 In fact: an URL
resource type
 http://server.org/fhir/Patient/1
endpoint identifier
“Business” identifiers
Resource metadata
Metadata
Patient Resource Identities

http://fhir.hl7.org/Patient/23E455A3B
MRN 22234 http://fhir.hl7.org/Patient/23E455A3B/_history/4
“Ewout Kramer”
30-11-1972
Amsterdam Last updated
2013-12-23T23:33:01+01:00
http://hl7.org/fhir/tag
http://example.org/fhir/Status#Test
http://hl7.org/fhir/tag/profile
http://hl7.org/fhir/Profile/us-core
How FHIR uses RESTful principles to communicate Resources
REST SERVICE INTERFACE
REST?
 “REpresentational State Transfer”

 Represent your data as “resources”
 Make “Resources” URI addressable
 Use HTTP to do CRUD operations
 Resources may be exchanged using
different representations
Possibly distributed…
FHIR server @ pat.registry.org FHIR server @ lab.hospitalA.org

Patient/223 DiagnosticReport/4445 Observation/3ff27
Patient subject Diagnostic Observation
Report
FHIR server @ hospitalA.org

Organization/1 Practitioner/87
Organization Practitioner
“Repository” model of
healthcare
Hospital System Lab System
Create Create Create

Query Query Subscribe
Update Update Update
Patient Diagnostic Observation

Patient Observation
Patient Report Observation
Organization
FHIR server
Just a quick GET
GET /fhir/patient/1 HTTP/1.1

HTTP Verb + path
HTTP/1.1 200 OK
Content-Type: application/xml+fhir;charset=utf-8
Content-Length: 787
Content-Location:
http://spark.furore.com/fhir/Patient/1/_history/12
Last-Modified: Tue, 29 May 2012 23:45:32 GMT
UTF-8
encoded
<?xml version="1.0" encoding="UTF-8"?>
<Patient xmlns="http://hl7.org/fhir"><identifier><label>SSN</label><identifier><system>
http://hl7.org/fhir/sid/usssn</system><id>444222222</id></identifier></identifier><name><use>official
</use><family>Everywoman</family><given>Eve</given></name><telecom><system>phone</system><value>555-
555 2003</value><use>work</use></telecom><gender><system>http://hl7.org/fhir/sid/v2-0001</system>
<code>F</code></gender><birthDate>1973-05-31</birthDate><address><use>home</use><line>2222 Home
Street</line></address><text><status>generated</status><div
xmlns="http://www.w3.org/1999/xhtml">Everywoman, Eve. SSN:444222222</div></text></Patient>
See the BOM?
A Resource’s REST identity
 In fact: an URL
resource type
 http://server.org/fhir/Patient/1
endpoint identifier
Note: This URL resolves to the current version of a resource
Remember metadata?
Metadata
Patient Resource Identities

MRN 22234 http://fhir.hl7.org/Patient/23E455A3B/_history/4
“Ewout Kramer”
30-11-1972
2013-12-23T23:33:01+01:00
Tag metadata
GET /fhir/Patient/1 HTTP/1.1
HTTP/1.1 200 OK
Content-Location: http://server.com/fhir/Patient/1/_history/12
Category: http://example.org/fhir/Status#Test;
scheme="http://hl7.org/fhir/tag"; label="Our test tag"
http://hl7.org/fhir/tag A general tag

A profile tag - a claim that the Resource
http://hl7.org/fhir/tag/profile conforms to the profile identified in the
term
http://hl7.org/fhir/tag/security A security label
Mapping (meta)data to
HTTP
 Resource data  http body

 Resource id  Url
 Resource version  Content-Location
header
 Last update date  Last-Modified header
 Tags  Category header
REST “representations”
GET /fhir/Patient/1?_format=json HTTP/1.1
HTTP/1.1 200 OK
Content-Type: application/json+fhir;charset=utf-8
Content-Length: 787

Accept: application/json+fhir
HTTP/1.1 200 OK
Content-Type: application/json+fhir;charset=utf-8
Content-Length: 787
Updating, creating & deleting single resources using REST
REST – CRUD & VERSIONS
One more look at the
header
HTTP/1.1 200 OK
Content-Type: application/xml+fhir;charset=utf-8
Content-Length: 787
Content-Location:
http://spark.furore.com/fhir/Patient/1/_history/12
For a specific version…
 We have the version-specific URL
endpoint
http://server.org/fhir/ (continued)
resource type
Patient/1/_history/4
identifier version id
Question
DO I REALLY HAVE TO IMPLEMENT

VERSIONS?
NO, You are not required to keep history, and may return
410 (Gone) on a “vread” for any request for an older version
than the current one!
REST in the spec
Let’s look at these operations in the

specification….
Mapping to verbs
create 2.1.10
The create interaction creates a new resource in a server assigned location. The create
interaction is performed by an HTTP POST operation as shown:
POST [service-url]/[resourcetype] (?_format=mimeType)
read 2.1.6
The read interaction accesses the current contents of a resource. The interaction is
performed by an HTTP GET operation as shown:
GET [service-url]/[resourcetype]/{id} (?_format=mimeType)
update 2.1.8
The update interaction creates a new current version for an existing resource or creates a
new resource if no resource already exists for the given id. The update interaction is
performed by an HTTP PUT operation as shown:
PUT [service-url]/[resourcetype]/{id} (?_format=mimeType)
delete 2.1.9
The delete interaction removes an existing resource. The interaction is performed by an
HTTP DELETE operation as shown:
DELETE [service-url]/[resourcetype]/{id}
Exercise #1
Fiddling around with Fiddler

&
Getting data from a FHIR test
server
(20 minutes)
Exercise #1
 Install Fiddler2
 Try getting a single patient:
• GET a patient with id ‘example’ (on spark.furore.com/fhir)
• Look at the response headers and validate that they are correct.
• Look at the xml and try to find an extension
• Find a resource reference and fetch the referenced Resource
• Try to get the same patient in JSON
‒ Using the _format parameter
‒ Using an Accept header
When you do a GET on a resource, there is another URL present

in the header. What happens if you try to GET that url?
The basic building blocks of FHIR
DECONSTRUCTING THE
FHIR DATAMODEL
The FHIR Elements
Composite Constrained
Metadata Types
Datatypes
(HumanName, (Quantity:
Quantity, Period, Distance, Count,
Address, Identifier )
Narrative Duration, Money)
use
Resource
Elements use
use
Primitives Derived
(integer, boolean,
string, instant) Primitives
(oid, uuid,
code, id)
Start at the bottom:
Primitives
boolean xs:boolean Values can be either true or false
integer xs:int A signed 32-bit integer
A rational number. A true decimal, with
decimal xs:decimal
inbuilt precision (e.g. Java BigDecimal)
base64Binary xs:base64Binary A stream of bytes, base64 encoded
An instant in time - known at least to the
instant xs:dateTime second and always includes a
timezone.
string xs:string A sequence of Unicode characters.
uri xs:anyURI A Uniform Resource Identifier Reference.
union of xs:date,
A date, or partial date as used in
date xs:gYearMonth,
human communication. No time zone.
xs:gYear
union of xs:dateTime, A date, date-time or partial date as used

xs:date, in human communication. If hours and
dateTime
xs:gYearMonth, minutes are specified, a time zone must
xs:gYear be populated.
Derived primitives
 Using the ISO date/time with timezone

 “1951”, “1951-06” and “1951-06-04”
 “1951-06-04T10:57:34.0321+01”
 “1951-06-04T10:57:34.0321Z”
Level up:
Composite Datatypes
Datatypes
Let’s take a look at the “Data Types” section of the FHIR

specification at
http://www.hl7.org/implement/standards/fhir/datatypes.html
Coded types
Codes are defined in code systems
Coded types
 When used in a Resource, the modelers

include Bindings
 Bindings specify which codes can be used
• Publication meta-
data
• Concepts from 1 or
more existing
systems
• Additional concepts
62
Level up: resources
“Choice” properties
References
Quick look at extensions
Metadata
Narrative
Resource
Elements
Extensions
Patient
MRN 22234
+ Haircolor BROWN
“Ewout Kramer”
30-11-1972 You can extend:
Amsterdam - Resources
- Elements of Resources
- FHIR Datatypes
Organization
“ACME Hospital”
National Drive 322
Orlando, FL
+ Taxoffice Id NLOB33233
Extending a multiple birth
Key = location of formal definition
Value = value according to definition
Complex extensions
Quick look at narrative
Metadata
Narrative
Resource
Elements
Narrative
Exercise #2
Editing a Resource Instance -

by hand!
(45 minutes)
Exercise #2
 Store the patient from last exercise somewhere on
your machine.
 Look up the Patient resource and update it to match

your own situation.
Lookup the specification of Patient to see if there are
other relevant elements you could use
 Try to add an extension for your hair color
 Try creating a new patient on the FHIR server with

this data
Why is hair color not a standard element on Patient?

Would you make an extension for it? Are there (better?)
alternatives for communicating a hair color?
How FHIR uses Atom to communicate sets of resources
BUNDLES
Communicating lists
 We need to communicate lists of Resources

 Search result
 History
 Documents or messages
 Multiple-resource inserts (“batches”)
 So, we need an industry-standard to
represent lists, and a place to put our
metadata
Bundle
Resource
Metadata
Metadata
Bundle Resource
Narrative
Resource
Elements
Extensions Resource
Extensions
Bundles
 Atom RFC 4287 + Tombstones RFC 6721
 Poll-based protocol for keeping up-to-date

with newsfeeds (RSS and Atom)
 You can “subscribe” to a FHIR feed and get

updates
An example Bundle
Resource metadata
Metadata
Patient Resource Identity

MRN 22234
“Ewout Kramer”
30-11-1972
2013-12-23T23:33:01+01:00
Resource Entry
Resource id
Last modified
Tags
Version specific id
Resource content
Human-readable form,
just like Resource.text
SEARCH FUNCTIONALITY
Getting “all” patients
 http://server.org/fhir/Patient
 Always returns a paged feed
 Use _count to indicate number of results per page
 Special case of the “real” search operation:

http://server.org/fhir/Patient/_search?name=eve
http://server.org/fhir/Patient?name=eve
Search (patient)
Each resource has a set of “standard”
search operations, so not every element
can be searched!:
Our last search

used this one
Demo
Performing simple searches

Let’s try this out
WHAT’S NEXT?
Next Steps for you
 Read the spec: http://hl7.org/fhir

 Try implementing it
 Come to a Connectathon!
 fhir@lists.hl7.org
 #FHIR
 Implementor’s Skype Channel
 StackOverflow: hl7 fhir tag
International Working Group Meeting
Mark Your Calendar and Join Us!
Paris, France
May 10 – 15
88
International HL7 FHIR Developer Days
November 18-20, 2015 in Amsterdam
 Education
 Tutorials
 Connectathon
 Meet fellow developers
 Put FHIR to the test
 Networking
 FHIR experts and authors on hand
http://fhir.furore.com/devdays
The End –
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Catching FHIR

 Name: Ewout Kramer

Relative – No technology can make integration as fast as we’d like

That’s why we’re here

Building blocks – more on these to follow

 Specification is written for one target audience:

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

// JsonTextReader jr = new JsonTe

 Delphi, C#, Java – more to come

 Connectathons to verify specification approaches

 Design for the 80%, not 100%

 Simple choice – design for absolutely

 Exchanges use XML & JSON

 FHIR supports 4 interoperability paradigms

Receive a lab result in a message…

FHIR Message FHIR

…Package it in a discharge summary document

 V2: Sort of like Segments

 CDA taught HL7 a very important lesson

Let’s take a look at some Resources in

 FHIR makes composition and references

Simple & Complex

Not an “electronic” version of a patient file…

Patient Resource Identities

REST SERVICE INTERFACE

 “REpresentational State Transfer”

FHIR server @ pat.registry.org FHIR server @ lab.hospitalA.org

FHIR server @ hospitalA.org

Create Create Create

Patient Diagnostic Observation

GET /fhir/patient/1 HTTP/1.1

Note: This URL resolves to the current version of a resource

Patient Resource Identities

GET /fhir/Patient/1 HTTP/1.1

http://hl7.org/fhir/tag A general tag

 Resource data  http body

GET /fhir/Patient/1?_format=json HTTP/1.1

GET /fhir/Patient/1 HTTP/1.1

REST – CRUD & VERSIONS

 We have the version-specific URL

DO I REALLY HAVE TO IMPLEMENT

Let’s look at these operations in the

Fiddling around with Fiddler

When you do a GET on a resource, there is another URL present

union of xs:dateTime, A date, date-time or partial date as used

 Using the ISO date/time with timezone

Let’s take a look at the “Data Types” section of the FHIR

Codes are defined in code systems

 When used in a Resource, the modelers

Key = location of formal definition

Value = value according to definition

Editing a Resource Instance -

 Look up the Patient resource and update it to match

 Try to add an extension for your hair color

 Try creating a new patient on the FHIR server with

Why is hair color not a standard element on Patient?

 We need to communicate lists of Resources

 Atom RFC 4287 + Tombstones RFC 6721

 Poll-based protocol for keeping up-to-date

 You can “subscribe” to a FHIR feed and get

Patient Resource Identity

 Always returns a paged feed

 Use _count to indicate number of results per page