PRINCIPLES OF HEALTH INTEROPERABILITY : fhir, hl7 and snomed ct.

482 Pages·2020·10.274 MB·English

by  TIM BENSON

Health Information Technology Standards
Series Editor: Tim Benson
Tim Benson
Grahame Grieve
Principles
of Health
Interoperability
FHIR, HL7 and SNOMED CT
Fourth Edition
Health Information Technology
Standards
Series Editor
Tim Benson
R-Outcomes Ltd
London, UK
Health information technology is one of the fastest growing industry sectors. The
purpose of this book series is to provide monographs covering the rationale, content
and use of these and other standards to help bridge the gap between the need for and
availability of qualified and knowledgeable staff. This series will be focused on
health informatics technology standards and the technology driving change in health
IT. It will appeal to the traditional informatics market, but also cross over into more
technical disciplines, but without leaving the remit that this is to expand knowledge
in healthcare IT. It will comprise a set of single-author, practically focused,
academically driven concise reference monographs on the leading standards and
their application. Each volume will focus on one or more specific standards and
explain how to use each one individually or in combination. This provides a tight
focus for each book. The aim is to offer a set of “must have” references on the
widely used standards, and in particular those mandated by the ONC.
More information about this series at http://www.springer.com/series/10471
Tim Benson • Grahame Grieve
Principles of Health
Interoperability
FHIR, HL7 and SNOMED CT
Fourth Edition
Tim Benson Grahame Grieve
R-Outcomes Ltd Health Intersections Pty Ltd
Newbury, UK Melbourne, VIC, Australia
ISSN 2199-2517 ISSN 2199-2525 (electronic)
Health Information Technology Standards
ISBN 978-3-030-56882-5 ISBN 978-3-030-56883-2 (eBook)
https://doi.org/10.1007/978-3-030-56883-2
© Springer Nature Switzerland AG 2016, 2021
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword
Principles of Health Interoperability: FHIR HL7 and SNOMED CT offers a reality
tested view of interoperability and the activities that are required for success in link-
ing clinical and financial data flows. Importantly, Tim and Grahame are not just
folks who have implemented systems; they are two of the pioneers who built the
standards we use (SNOMED and FHIR, respectively) to begin with. Thinking about
the value of this book requires pondering why interoperability in healthcare is hard.
Many commentators have tried to reason by analogy using financial services as
a starting point—typically stating “I can use my ATM card anywhere on the planet,
why can’t I get my medical record?” ATM transactions are inherently representable
as limited sets of numbers and a modest amount of metadata. Biology is infinitely
complex—we simply do not know what every molecule in every cell does and rep-
resenting the three-dimensional interactions of each atom in the body is beyond
computation. So interoperability in healthcare is inherently an exercise in extreme
reductionism.
Many clinicians rightfully expect all data to be simply available. While much
data can be entered by machines such as MRI scanners or lab analyzers, much criti-
cal information comes to clinicians from talking with and interacting with patients.
Speech recognition and natural language processing have made strong advances but
ultimately we still require human brains to gather and enter critical data. The time
to do this data entry and organization is not free—as with any system where one is
fighting entropy; it requires injecting energy, in particular thoughtful (and expen-
sive) clinician time. But how can these humans we guided enter this data in a way
that is “interoperable”?
So we see interoperability is not a simple exercise in data transformation, or an
exercise in “more regular expressions please,” but as a computational activity requir-
ing compression of information to a level that is tractable. It must also be done in a
way that is respectful of clinician time both in retrieving the information and more
importantly in entering the information.
Tim and Grahame provide a richly thought-provoking narrative on how to reach
these almost inherently unachievable goals. They have been successfully working to
move interoperability forward for many years.
This is the fourth edition of the book. What has changed? When discussions of
interoperability were first raised in healthcare, it was a monumental challenge to
build any networking infrastructure. Today, we live in a world rich in bandwidth, but
v
vi Foreword
more importantly in a world where the communications are not just between clini-
cians, but between and among patients. Today, the electronic health record still
remains the centerpiece of interoperability. But we are moving into a world with
multiple types of interactions, where clinical information needs to flow. We are
moving into a world, where patients expect to be stewards and controllers of their
own data—a critical requirement for healthcare that is truly patient-centered as
opposed to medical care today which is primarily the creation of providers, payers,
and the governmental regulations that direct these third parties. RESTful, JSON,
and FHIR are becoming the lingua franca of a more encompassing view of health
and healthcare. Be ready as Tim and Graham lead the way to this modern approach
to interoperability.
Interoperability in healthcare is a global movement and standards are being
developed across the planet. This is a theme throughout the book. Many countries
are working to enable modern support for interoperability and hence health to their
citizens. We, in the USA at the Office of the National Coordinator for Health
Information Technology (a division of the US Department of Health and Human
Services), have been proud to play a key role in implementing the bipartisan vision
for interoperability embodied in the US law known as the 21st Century Cures Act,
and we are delighted to be able to work with global standards community to achieve
this vision. Please enjoy this book—a wonderful roadmap to modern healthcare.
Thank you Tim and Grahame.
National Coordinator for Health Information Technology Donald W. Rucker
US Department of Health and Human Services,
Washington, DC, USA
Preface
This fourth edition of Principles of Health Informatics has been updated, reordered,
and revised to focus on the health interoperability standards that are most important
in the 2020s, with an emphasis on HL7 FHIR (Fast Healthcare Interoperability
Resources). The success of FHIR has already exceeded expectations. It is now man-
dated for large-scale use in many countries, including the USA and the UK.
Healthcare is about to enter a period of tumultuous change driven by the wider
trends driving rapid change in society, partly driven by digital disruption and social
media. Health informatics sits right at the middle, the intersection between manage-
ment and business, clinical knowledge and process, and technology and information
management. It is our hope that this book makes a small contribution towards help-
ing us all meet the challenge.
Interoperability standards and implementation guides have voluminous docu-
mentation. Our intention is to introduce the core stable principles that change rarely
in a relatively concise way. This book complements longer guides which are tai-
lored to local needs and are often updated frequently.
The introduction to clinical terminology has been promoted (Chap. 3), and there
is a new chapter on safety (Chap. 4). Chapters on FHIR (Fast healthcare
Interoperability Resources) have been extended, updated for FHIR Release 4 and
moved forward (Chaps. 5–11), and the section on LOINC has been extended to a
full chapter (Chap. 17). Chapters on privacy, models, UML, BPMN, XML and
JSON, SDOs, and HL7 v3 have been moved towards the back.
Newbury, UK Tim Benson
Melbourne, VIC, Australia Grahame Grieve
vii
Contents
Part I P rinciples of Health Interoperability
1 The Health Information Revolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Healthcare Is Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
What People Want . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Person-Centered Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Information Handling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Use of Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Clinical Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Success and Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
NASSS Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Lessons from History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2 Why Interoperability Is Hard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Layers of Interoperability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Why Standards Are Needed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Combinatorial Explosion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Translations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Electronic Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
ISO 13606 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Problem-Oriented Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
The Devil Is in the Detail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Name and Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Clinical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Complexity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Complexity Creates Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Users and Vendors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Change Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Behaviour Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
ix
x Contents
3 Clinical Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Medical Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Medical Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Coding and Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
User Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Model of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Model of Meaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Desiderata . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
The Chocolate Teapot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
A Fictitious Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4 Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
First, Do No Harm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Safety Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Impact of Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
London Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Application Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
FHIR Safety Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Part II FHIR
5 Principles of FHIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Origins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
APIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
RESTful Interfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Repository . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Resource Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
References Between Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Extensibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
FHIR Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Relationships with Other Organisations . . . . . . . . . . . . . . . . . . . . . . . . 97
The FHIR Manifesto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
FHIR Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100