PRINCIPLES OF HEALTH INTEROPERABILITY : fhir, hl7 and snomed ct. [4 ed.] 9783030568825, 3030568822

Table of contents :
Foreword
Preface
Contents
Part I: Principles of Health Interoperability
1: The Health Information Revolution
Healthcare Is Communication
What People Want
Person-Centered Care
Rules for the Twenty-First Century Health Care System
Waste
Information Handling
Use of Information
Clinical Decisions
Success and Failure
NASSS Framework
Lessons from History
El Camino Hospital
Success in GP Surgeries
Failure in Hospitals
NHS National Programme of IT
Denmark
Meaningful Use
References
2: Why Interoperability Is Hard
Layers of Interoperability
Definitions
Technical Interoperability
Semantic Interoperability
Process Interoperability
Clinical Interoperability
Incentives
Why Standards Are Needed
Combinatorial Explosion
Translations
Electronic Health Records
ISO 13606
EHR
Folder
Composition
Section
Entry
Cluster
Element
Data Value
Problem-Oriented Medical Records
The Devil Is in the Detail
Name and Address
Clinical Information
Clinical Reports
Primary Care Records
Complexity
Complexity Creates Errors
Users and Vendors
Change
Change Management
Behavior Change
COM-B
The 3 laws of Interoperability
References
3: Clinical Terminology
Medical Language
Background
Medical Terms
Coding and Classification
Coding
Classification
Hierarchy
Position-Dependent Codes
Definitions
Code
Concept
Display Term
Expression
Identifier
Interface Terminology
Ontology
Position-Dependent Coding Scheme
Reference Terminology
Relationship
Terminology
Value Set
User Requirements
Model of Use
Ad Hoc Data Entry
Structured Data Entry
Multiple Views
Model of Meaning
Desiderata
Vocabulary Content
Concept Orientation
Concept Permanence
Non-semantic Concept Identifiers
Polyhierarchy
Formal Definitions
Reject “Not Elsewhere Classified”
Multiple Granularities
Multiple Consistent Views
Context Representation
Graceful Evolution
Recognize Redundancy
The Chocolate Teapot
A Fictitious Example
Starting Simple
Basic evolution
Complications Arise
Errors are found
Subsets Are Developed
References
4: Safety
First, Do No Harm
Safety Principles
Definitions
Impact of Change
Culture
London Protocol
Application Design
FHIR Safety Checklist
Full Life-Cycle
Modifiers
ModifierExtensions
Must Support
Distributed Resource Identification
Current Resources
HTTP Errors
Capability Statement
Validation
Implicit Rules
Consent
Encryption
Security Labels
Narrative
References
Part II: FHIR
5: Principles of FHIR
Introduction
Benefits
Origins
Consistency
Complexity
Conformance Testing
APIs
RESTful Interfaces
Repository
Resources
Resource Types
References Between Resources
Extensibility
Problems with Z-Segments
Extensions in FHIR
Narrative
FHIR Community
Relationships with Other Organizations
DICOM
IHE
SNOMED International
LOINC
SMART Health
The 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 and Architectures
FHIR Development
Agile Development
FHIR Maturity Model
6: The FHIR API
Introduction
Common Behavior
Security
XML or JSON
HTTP Version
Error Handling
Base RESTful API Services
System Service
Capability Statement
Batches and Transactions
System Wide History
System Search
Type Service
Create New Resource
Type Specific History
Search
Joining Using Search
What Search Is Not
Instance Service
Read
Update
Delete
Resource History Service
Additional Services
Operations
Operation Definitions
Compartments
Subscription
Version Tracking
Bulk Data API
ND-JSON Format
Invoking HTTP Operations Asynchronously
Initiation
Progress
Operations
7: Resource Basics and Datatypes
Resource Definitions
Representation
UML
XML
JSON
JSON vs. XML
Choice Elements
Modifier Elements
Invariants
FHIRPath
Common Features
Logical ID
Common Metadata
VersionId/LastUpdated
Profiles
Security Labels
Tags
Implicit Rules
Language
Other Common Features
FHIR Data Types
Primitive Data Types
Decimal
Complex Data Types
HumanName
Identifier
Coding/CodeableConcept
Coding
Quantity
Timing
8: Selected Resources
Important Resources
Participation Resources: Background
Patient
Bundle
List
Composition
OperationOutcome
Parameters
Forms and Questionnaires
Uses
Questionnaire
Questionnaire Content
QuestionnaireResponse
QuestionnaireResponse Content
Relationships with Other Resources
Workflow
Static Forms
Adaptive Questionnaire
Pre-population
9: Conformance, Terminology and Profiles
Conformance
Adaptations
Common Conformance Metadata
Terminology
Code System
Coding/CodeableConcept
Binding
Value Set
Content Logical Definition
Expansion
Terminology Server
Element Definition
Profiles
StructureDefinition
Differential and Snapshot
Slicing
Must Support
Using Profiles
Behavior
CapabilityStatement
OperationDefinitition and SearchParameter
Managing
ImplementationGuide
TestScript
10: Implementing FHIR
Implementation Focus
Connectathon
Organizing a Connectathon
Organizer Role
Storyboards
Outcome
Virtual Connectathon Events
Considerations
Architecture
Push, Pull or Pub/Sub
XML or JSON
Managing Resources
Identification
Versioning
NPM Packages
Server Implementation
Tools
Reference Implementations
JAVA/HAPI
DotNet/C#
Pascal
Other Open-Source Reference Implementations
National Specifications
US Core FHIR Implementation Guide
US Core Patient
Challenges with National Specifications
Argonaut Project
International Patient Specifications
11: Security & Integrity in FHIR
Encryption and TLS
Cryptography
Symmetric Key Cryptography
Public Key Certificates
Private Keys
Digital Signature
Encryption
TLS
Objectives
Protocols
Properties
Privacy
Security
Authentication
Reliability
Methods
Mutual TLS
Current Minimum Requirements
Access Control and Security Labels
Security Labels
User Management
OAuth
Smart on FHIR
Launch Sequences
Authorization and Authentication
Provenance Tracking and Audit Trails
Provenance
Heritage
Contents
Using Provenance
Audit Trails
Heritage
Contents
When to use Provenance or AuditEvent
Security Issues around Narrative and String Content
References
Part III: Other Exchange Standards
12: HL7 Version 2
Introduction
Message Syntax
Delimiters
Segment Separator
Field Separator (|)
Component Separator (^)
Subcomponent Separator (&)
Repetition Separator (~)
Escape Character (\)
Segment Definition
Segments
Message Header (MSH)
Event Type (EVN)
Patient Identification Details (PID)
Patient Visit (PV1)
Request and Specimen Details (OBR)
Result Details (OBX)
Z-Segments
Worked Example
Message Structure
Populated Example
Data Types
Simple Data Types
Complex Data Types
Codes and Identifiers
Names and Addresses
HL7 v2 Tables
Further Reading
The following books only cover HL7 v2.
13: CDA—Clinical Document Architecture
Document Paradigm
Properties
Persistence
Stewardship
Authentication
Wholeness
Readability
CDA History
Levels
Level 1
Level 2
Level 3
Releases
Release 1
Release 2
Header
Example—Normal Confidentiality
Participitations
Patient
Author
Steward
Other Participants
Relationships
Parent Document
Service Event
Encounter
Order
Consent
Body
Section
Clinical Statement
Specializations
Observation
Procedure
Encounter
Substance Administration
Supply
Organizer
Act
Relationships Between Entries
CAUS
COMP
GEVL
MFST
RSON
SAS
SPRT
CDA Template
Continuity of Care Document (CCD)
CCD Header
CCD Body
Consolidated CDA (C-CDA)
References
14: IHE XDS
Sharing Documents
Metadata Standards
Documents and Statements
Clinical Document
Clinical Statement
Requirements
How XDS Works
Affinity Domain
Document Registry
Document Source
Document Repository
Document Consumer
Patient Identity Source
XDS Metadata
Coded Attributes
Document Data
classCode Required [1..1]
typeCode Required [1..1]
uniqueId Required [1..1]
entryUUID Required [1..1]
confidentialityCode Required [1..*]
availabilityStatus Required [1..1]
languageCode Required [1..1]
Title Optional [0..1]
Patient Data
patientId Required [1..1]
sourcePatientId Required [1..1]
sourcePatientInfo Optional [0..1]
Author Data
Author Required if Known [0..*]
authorPerson Required if Known [0..1]
authorInstitution Required if Known [0..*]
authorRole Required if Known [0..*]
authorSpecialty Required if Known [0..*]
legalAuthenticator Optional [0..1]
Event Data
creationTime Required [1..1]
healthcareFacilityTypeCode Required [1..1]
practiceSettingCode Required [1..1]
eventCode Optional [0..*]
serviceStartTime Required if Known [0..1]
serviceStopTime Required if Known [0..1]
Technical Data
homeCommunityId Required [1..1]
repositoryUniqueId Added by Repository [1..1]
formatCode Required [1..1]
Size Computed by Repository [1..1]
Hash Computed by Repository [1..1]
mimeType Required [1..1]
Comments Optional [0..*]
Submission Sets and Folders
XDS Extensions
Point to Point Transmission
XDM—Cross-Enterprise Document Media Interchange
XDR—Cross-Enterprise Document Reliable Interchange
Direct Project
Health Information Service Provider (HISP)
Information Retrieval
DSUB—Document Metadata Subscription
MPQ—Multi-Patient Queries
MHD—Mobile Access to Health Documents
Security Profiles
ATNA—Audit Trail and Node Authentication
BPPC—Basic Patient Privacy Consent
DSG—Document Digital Signature
XUA—Cross-Enterprise User Authentication
XCA—Cross Community Access
References
Part IV: Terminology
15: Classifications
Introduction
ICD
ICD-10
ICD-11
DRGs
The Read Codes
Hierarchical Codes
Automatic Encoding
Main Hierarchies
Diseases
Procedures
History/Symptoms
Occupations
Examination/Signs
Prevention
Administration
Drugs
Evolution
Why Read Codes Were Successful
Problems with the Read Codes
SNOP and SNOMED
UMLS
References
16: SNOMED CT
Introduction
Origins
Components
Concept
Description
Relationship
Defining Relationships
Qualifying Relationships
Additional Relationships
Hierarchies
Identifier
Expressions
Compositional Grammar
Subtype Qualification
Axis Modification
Subsumption Testing
Transitive Closure
Concept Model
Hierarchies
Object Hierarchies
Value Hierarchies
Miscellaneous Hierarchies
Attributes
Concept Model Attributes
Unapproved Attributes
Concept History Attributes
Object Hierarchies
Clinical Finding
Procedure
Situations with Explicit Context
Observable Entity
Event
Staging and Scales
Specimen
Value Hierarchies
Body Structure
Organism
Substance
Pharmaceutical/Biologic Product
Physical Object
Physical Force
Social Context
Environments and Geographic Locations
Miscellaneous Hierarchies
Qualifier Value
Special Concept
Record Artifact
Model Components
Core Metadata Concept
Foundation Metadata Concept
Linkage Concept
Namespace Concept
Reference Sets
Introduction
Subset
Value Set
Refset
Reference Set Development
Reference Set Types
Simple Reference Set
Query Specification Reference Set
Ordered Reference Set
Association Reference Set
Ordered Association Reference Set
Annotation Reference Set
Attribute Value Reference Set
Language Reference Set
Human-Readable Reference Set
Map Reference Sets
Deployment
Releases
Documentation
SNOMED CT Starter Guide
SNOMED CT Technical Implementation Guide
SNOMED CT Editorial Guide
Practical Guide to Reference Sets
References
17: LOINC
Background
Rationale
Principles
Openness
Accessibility
Growth
Pragmatics
Agility
Diligence
Respect
Components
Code
Name
Parts
Component
Property
Time Aspect
System
Scale Type
Method Type
Panels
Laboratory LOINC
UCUM
Clinical LOINC
Assessments
Hierarchy
Answers
Other Attributes
An Example: howRu
Distribution
RELMA
References
18: Using Terminology
Introduction
Terminology Binding
Structural Models
ISO 13606 Reference Model
Archetypes
Templates
nullFlavors
CodeSystem
OriginalText
displayName
Translations
Value Set vs Code System
Complex Coded Expressions
Common Scenarios
#1: Coded Text When the Correct Code Is Known
#2: Coded Text When the Correct Code Is Not Known
#3: Codeable Text When the Value (Coded or Not) Is Not Known
#4: Codeable Text When User Picks Code Directly from Expected Value Set
#5: Codeable Text When User Enters Text
#6 Codeable Text When User Picks Code Directly from Another Code System
Quantity
#8 Codeable Text When User Chooses a Self-Defined Code
#9 Codeable Text—CDA Generated on an Interface Engine from HL7 v2
Advice for Receivers
Issues
Coding Level
Data Entry
Data Retrieval
Communication
Expression Storage
When to use HL7 and SNOMED
Grey Areas
References
Part V: Miscellaneous
19: Privacy and Consent
To Share or Not to Share
Regulations
GDPR
Privacy Requirements
Confidentiality
Integrity
Availability
Accountability
Administration
Assurance
IG Policy
Authentication
Authorization
Role
Purpose
Consent
Explicit Consent
Implied Consent
Opt-in and Opt-out Consent
Delegated Consent
Operating Procedures
Consent Directive
Access Control
Rights and Obligations
Other Services
Anonymization
Pseudonymization
Audit Trails
References
20: Models
Importance
Model Driven Architecture
Models in Interoperability Standards
Lifecycle
Scope
Storyboards
Requirements
Business Analysis
Conceptual Design
Comprehensive
Context Explicit
Complete in Itself
Consistent
Compatible
Composable
Comprehensible
Conformance-testable
Technology-Specific Specification
Examples
Esther
Fred and His Dog
Colorectal Cancer Referral
References
21: UML, XML and JSON
UML
Structure
Class
Navigation Arrows
Multiplicity
Composition and Aggregation
Inheritance
Attribute
Operation
Object
Package
Deployment
Behaviour
Use Case
Activity Diagram
Sequence Diagram
State Chart
BPMN
Business Process
Participant
Event
Gateway
Connector
XML
Structure
Element
Comment
Attribute
Entity
Checking
Well-formed
Valid
Schema
Schema Definition
Namespaces
Stylesheet
XPath
JSON
Origins
Syntax
Comparing JSON to XML
Tools
Browser+JavaScript
JSON Query
JSON Schema
Implementation Issues
Text Escaping
Numbers
Dates
Property Names
Property Uniqueness
Property Order
Converting between XML and JSON
References
22: Standards Development Organizations
Standards
What is a Standard?
Definitions
Types of Standards
The Business Case
How Standards Bodies Work
How HL7 Works
Ten Commandments
Organizations
Joint Initiative Council
ISO/TC 215
CEN/TC 251
HL7 International
HL7 Products
Ballot Process
Membership
The Technical Steering Committee
SNOMED International
DICOM
IHE
PCHAlliance
CDISC
OpenEHR
Clinical Data Repository
Two-Level Information Modelling
Archetype
Template
FHIR Foundation
References
23: HL7 v3
The v3 RIM
Origins of v3
Overview
The RIM Backbone
Structural Attributes
Common Attributes
Act
classCode
moodCode
activityTime and effectiveTime
Observation
Procedure
SubstanceAdministration
Supply
PatientEncounter
Entity
Person
LivingSubject
Role
Association Classes
ActRelationship
RoleLink
V3 Data Types
Basic Data Types
Instance Identifier
Code Data Types
Dates and Times
Name and Address
Generic Collections
Special Fields
Use of the RIM
Constraints on the RIM
R-MIMs
What Happened to the RIM?
References
Index

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