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Argonaut Data Query and US Core

Brett Marquard, WaveOne

Instructor

Brett Marquard

• Principal, WaveOne Associates

• Extensive EHR experience

• Primary Editor, Consolidated CDA (C-CDA)

• Primary Editor, Argonaut Data Query IG / US FHIR Core IG

• brett@waveoneassociates.com

Outline

Background on Argonaut

Data Query and Document Query

US Core

Future

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What is the Argonaut Project?

The Argonaut Project is an implementation community comprising leading technology vendors

and provider organizations to accelerate the use of FHIR and OAuth in health care information

exchange.

We are:

• Private sector initiated and funded

• Working collaboratively with other FHIR initiatives such as SMART-on-FHIR, the Health Systems

Platform Consortium, and the FHIR Foundation

• Creating open industry Implementation Guides in high priority use cases of importance to patients,

providers and the industry as a whole

We are NOT:

• A standards development organization

• A separate legal entity

• A proprietary activity

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Technology Vendors Provider Organizations

• Accenture • Beth Israel Deaconess Medical Center

• Apple • Intermountain Health

• athenahealth • Mayo Clinic

• Cerner • Partners Healthcare

• Epic • SMART at Boston Children’s Hospital • Change Healthcare

• MEDITECH

• Surescripts

• The Advisory Board Company/Optum

Staff (current and past)

• Prime contractor: HL7

• FHIR initiatives: Grahame Grieve, , Eric Haas, Josh Mandel, Brett Marquard

• OAuth initiatives: Dixie Baker, Josh Mandel

• Project Management: Jennifer Monahan, Micky Tripathi

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Clinical Identification Workflow Infrastructure Conformance FinancialAllergyIntolerance Patient Encounter Questionnaire ValueSet Coverage

Condition (Problem) Practitioner EpisodeOfCare QuestionnaireRespons ConceptMap Eligibil ityRequest

Procedure RelatedPerson Communication Provenance NamingSystem Eligibil ityResponse

ClinicalImpression Organization Flag AuditEvent StructureDefinition EnrollmentRequest

FamilyMemberHistory HealthcareService Appointment Composition DataElement EnrollmentResponse

RiskAssessment Group AppointmentResponse DocumentManifest Conformance Claim

DetectedIssue Location Schedule DocumentReference OperationDefinition ClaimResponse

CarePlan Substance Slot List SearchParameter PaymentNotice

Goal Person Order Media ImplementationGuide PaymentReconciliation

ReferralRequest Contract OrderResponse Binary TestScript ExplanationOfBenefit

ProcedureRequest Device CommunicationRequest Bundle

NutritionOrder DeviceComponent DeviceUseRequest Basic

VisionPrescription DeviceMetric DeviceUseStatement MessageHeader

Medication ProcessRequest OperationOutcome

MedicationOrder ProcessResponse Parameters

MedicationAdministration SupplyRequest Subscription

MedicationDispense SupplyDelivery

MedicationStatement

Immunization

ImmunizationRecommendation

Observation

DiagnosticReport

DiagnosticOrder

Specimen

BodySite

ImagingStudy

ImagingObjectSelection

Patient name

Sex

Date of birth

Race

Ethnicity

Preferred language

Smoking status

Problems

Medications

Medication allergies

Laboratory tests

Laboratory results

Vital signs

Procedures

Care team members

Immunizations

Unique Device identifiers

Assessment and Plan of Treatment

Goals

Health concerns

2015 Edition

Common Clinical Data Set 93 FHIR DSTU2 Resources (17 Argonaut CCDS Resources in red)

What does the Argonaut process do? Set priorities

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What does the Argonaut process do? Resolve practical problems

What search criteria can you

use?

What type of data will you

get in response?

How will that data be

represented?

Scope of response

Examples:

• Search for patient will get all

FHIR patient resources

• Search for Procedures will get

all current and historical

procedures or within specified

date range

Content of response

Examples:

• Patient search will get name,

identifier, gender, birthdate,

• Procedures search will get

type of procedure, date

performed, and procedure

status

• In some cases created

Argonaut extensions and value

sets

Search operations

Examples:

• Can search for individual

patient by identifier (e.g.,

MRN) OR full name & gender

OR full name & birthdate

• Can search for Procedures by

patient or by patient &

specified date range

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A Signature Event: Argonaut Data Query Implementation Guide

http://www.fhir.org/guides/argonaut/r2/

• Access to individual data

elements of Common Clinical

Data Set

• Access to structured document (CCD) containing all Common

Clinical Data Set elements

• Leverage OAuth2-based security

and authorization

US FHIR Core

The US FHIR Core is a labeled subset of all HL7 US-Realm produced FHIR profiles.

The label is designed to provide the community with a single point of reference to

foundational US FHIR profiles that:

1) should be used by US stakeholders when implementing FHIR; and

2) always be used as the basis for creating further US-Realm profiles.

Bottom line

• Argonaut IG = US Profiles on DSTU2

• US Core = HL7 balloted US Profiles on STU3. Built from Argonaut requirements.

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Argonaut and US Core STU3 Profiles

Argonaut AllergyIntolerance Profile

Argonaut CarePlan Profile

Argonaut CareTeam Profile

Argonaut Condition Profile

Argonaut Device Profile

Argonaut DiagnosticReport Profile

Argonaut DocumentReference Profile

Argonaut Goal Profile

Argonaut Immunization Profile

Argonaut Medication Profile

Argonaut MedicationOrder Profile

Argonaut MedicationStatement Profile

Argonaut Observation Results Profile

Argonaut Patient Profile

Argonaut Procedure Profile

Argonaut Smoking Status Observation Profile

Argonaut Vital Signs Observation Profile

US Core AllergyIntolerance Profile

US Core CarePlan Profile

US Core CareTeam Profile

US Core Condition (a.k.a Problem) Profile

US Core Device Profile

US Core DiagnosticReport Profile

US Core Goal Profile

US Core Immunization Profile

US Core Location Profile

US Core Medication Profile

US Core MedicationRequest Profile

US Core MedicationStatement Profile

US Core Organization Profile

US Core Patient Profile

US Core Practitioner Profile

US Core Procedure Profile

US Core Results Profile

US Core Smoking Status Profile

Vital Signs Profile (FHIR Core Profile)

January 2018 US Core Ballot

US Core DocumentReference Profile

US Core Encounter Profile

US Core PractitionerRole Profile

…final publication summer 2018!

© 2015 HL7 ® Int’l. Licensed under Creative Commons. HL7, Health Level Seven, FHIR & flame logo are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

®

®

Profile-less FHIR

You don’t need profiles to interoperate with FHIR

Resources are “discrete” enough that mechanism to populate most elements is clear

Approach

Populate/consume all elements you know, use HL7 or country-standard

extensions for extras

Map to/from “recommended” terminologies as much as possible, populate CodeableConcept.text

Expose capabilities in Conformance resource

© 2015 HL7 ® Int’l. Licensed under Creative Commons. HL7, Health Level Seven, FHIR & flame logo are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

® Profile-less FHIR

You don’t need profiles to interoperate with FHIR

Resources are “discrete” enough that mechanism to populate most elements is clear

Approach

Populate/consume all elements you know, use HL7 or country-standard

extensions for extras

Map to/from “recommended” terminologies as much as possible, populate CodeableConcept.text

Expose capabilities in Conformance resource

© 2015 HL7 ® Int’l. Licensed under Creative Commons. HL7, Health Level Seven, FHIR & flame logo are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

® Base Condition Resource vs.

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© 2015 HL7 ® Int’l. Licensed under Creative Commons. HL7, Health Level Seven, FHIR & flame logo are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

® US Core Condition

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Key Components – Data Query

General Guidance

Profiles

Extensions

Value Sets

Operations

Conformance

General Guidance

Mapping of FHIR to the ONC 2015 Common Clinical Data Set (CCDS)

‘Must Support’ • Base FHIR guidance -‘When a profile does this, it SHALL also make clear exactly what kind

of "support" is required.’

• Data Query - took us 6 bullets to say, ‘send these values if you have them’

Extensible + Max-ValueSet binding for CodeableConcept Datatype

• Allows for either a code from the specified value set or text

Using UCUM in the [Quantity] datatype

• Free text when necessary

http://www.fhir.org/guides/argonaut/r2/definitions.html

http://hl7.org/fhir/us/core/guidance.html

General Guidance

18 http://hl7.org/fhir/us/core/guidance.html

Profile Deep Dive – Allergies

Prose

Mandatory Elements

Profile Specific Guidance

Formal View

Search

GET /AllergyIntolerance?patient=[id]

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http://hl7.org/fhir/us/core/StructureDefinition-us-core-allergyintolerance.html

Profile Deep Dive – Allergies

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Profile – Patient

21

Profile – Patient Quick Start

22 http://hl7.org/fhir/us/core/StructureDefinition-us-core-patient.html

Extensions

US Core Race Extension

Profile-resource association extension

US Core ethnicity Extension

Email is a "direct" email

US Core Birth Sex Extension

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Value Sets - Terminology

23 Value Sets! US Core Substance-Reactant for Intolerance and Negation Codes US Core SNOMED CT Substances Other Than Clinical Drugs US Core Substance RxNorm Codes US Core Substance ND-FRT codes US Core Provider Speciality (NUCC) US Core Provider Role (NUCC) US Core ICD-10-PCS Procedure Codes US Core Procedure Codes Problem Value Set Observation Value Codes (SNOMED-CT) Smoking Status Vaccine National Drug Code (NDC) Narrative Status Medication Clinical Drug (RxNorm) Vaccine Administered Value Set (CVX) US Core Condition Category Codes

CareTeam Provider Roles US Core Birth Sex Value Set Language codes with language and optionally a region

modifier OMB Race Categories OMB Ethnicity Categories US-Core Detailed Race US-Core Detailed ethnicity

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Value Sets - Problem Value Set

25

.compose: A definition of which codes are intended to be in the value set ("intension" )

Value Sets - Smoking Status

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Operation - Get DocumentReferences ($docref)

This operation differs from a simple query in that DocumentReferences may be created ‘on-the-fly’ in response to this operation. For example, in some cases the documents themselves may not exist but can be generated when needed so a reference to them can be generated using this operation. If no documents exist and an ‘on-demand’ document cannot be created then the operation will return an empty search bundle.

CapabilityStatement (formerly know as Conformance)

Data Query Implementation Guide Server: The CapabilityStatement defines the expected capabilities of a server when conforming to the US Core Data Query Implementation Guide.

Data Query Implementation Guide Client:

This CapabilityStatement defines the expected capabilities of a client when conforming to the Argonaut Data Query Implementation Guide.

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CapabilityStatement (formerly know as Conformance)

29 http://hl7.org/fhir/us/core/capstmnts.html

Future of Argonaut + US FHIR Core

Argonauts

• Encouraged to use US FHIR Core rather than writing their own FHIR STU3 guide, or R4 guide.

• Piloting new R3 profiles for Clinical Notes and Questionnaires

US Core

• New STU3 publication summer 2018 to add DocumentReference, Encounter, and PractitionerRole

• Discussions at HL7 US Realm Steering Committee to add relevant Argonaut R3 profiles to US Core, such as Clinical Notes in winter 2018-2019 ballot.

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Interop thought experiment

Data vs Narrative Tug of war

Data

Internal Use Only © 2018 WaveOne Associates 33

Narrative – ‘the shoe bin’

Today, after returning from our walk Edison told us he wanted to put the boot bin away. I told him he could help if he got undressed, but he dawdled. I reminded him a couple of times if he wanted to put the boot bin away he would need to get undressed. He chose to watch other children and roll on the floor, so eventually I let him know that I was going to invite other children to put it away. He got very upset and actually cried :( We have seen similar experimental behaviors from Edison so we are working with Edison to link his actions to the consequences. Edison remembers things from the past and so we hark back onto those moments to help explain why he should cooperate or do as we ask.

Internal Use Only 34 © 2018 WaveOne Associates

Other School - Nothing

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Don’t lose the story!

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Clinical Notes…

Common Clinical Notes Set • Discharge documentation (18842-5)

• Consultation (11488-4)

• History & Physical (34117-2)

• Progress note (11506-3)

• Procedures note (28570-0)

• Future: Imaging narrative (18726-0) and Lab/path narrative

….Transfer note, Referral note, Surgical Operation note, Nurse note, Care Plan

Starter Set for testing and design - the value set will not be restricted to these 5

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Anticipated Note Formats

Text or XHTML

RTF or PDF or .doc

Mixed document: structured FHIR resources, and narrative

Progress Note

Connectathon Scenarios

1. Retrieve an Encounter Summary Note with DocumentReference id 2. Retrieve all notes by patient 3. Retrieve an Encounter Summary Note searching with a data range 4. Retrieve a Patient's Discharge Summary Notes 5. Write a new note to a Patient's Chart

Clinical Notes Track Scenario

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Participation

Review existing designs and comment use issues on GitHub

Zulip Chat Channels

• Bulk Data

• Argonaut

Upcoming HL7 Connectathon in Baltimore, MD (9/29 - 9/30)

Contact

• Eric Haas

• Josh Mandel

• Brett Marquard

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Additional Useful Links

FHIR Wiki

Public FHIR Servers for Testing

Proposed Connectathon Tracks September

HL7 Working Group Meeting Register Now!

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