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© 2013 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Introduction to FHIR
Grahame Grieve
March 25, 2015
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Today / Tomorrow
Versions for today/tomorrow: FHIR is a rolling target right now (>100
commits/day) Server: http://fhir-dev.healthintersections.com.au/open
Stable version of spec: http://fhir-dev.healthintersections.com.au/index.html
HAPI: http://fhirtest.uhn.ca/baseDstu2/
.Net RI: https://www.nuget.org/packages/Hl7.Fhir/0.11.1-alpha4
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WHAT IS FHIR?
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Answer: An instigator of bad puns
FHIR is the hottest thing since . . . This spec is spreading like . . . Committee X is really on FHIR Feel free to come up with your own
(but please, not here )
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The acronym
F – Fast (to design & to implement) Relative – No technology can make integration as
fast as we’d like H – Health
That’s why we’re here I – Interoperable
Ditto R – Resources
Building blocks – more on these to follow
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Adoption
FHIR is a draft standard A ‘beta’ standard subject to ongoing change
In spite of this, it is being adopted quickly Cited in US MU3 regulations (implicitly) Argonaut / HSPC projects – large US vendors National EHRs going live this year
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Introduction
Enables information exchange to support the provision of healthcare
Standard industry RESTful practices But more than just REST
Scope of FHIR is broad human and veterinary clinical care, public health, clinical trials administration and financial aspects
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Framework
Common features of all resources: A URL that identifies it Common metadata A human-readable XHTML summary A set of defined common data elements An extensibility framework
Represented as either XML or JSON
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Human Readable Summary
Standard Data Content: MRN Name Gender Date of Birth Provider
Extension with reference to its definition
Identity & Metadata
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Resources
Each resource consists of: resourceType id : The id of the resource Meta : Common use/context data text : XHTML - human readable Extensions : extensibility framework data - data elements for each resource type
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Create = POST https://example.com/path/{resourceType} Read = GET https://example.com/path/{resourceType}/{id} Update = PUT
https://example.com/path/{resourceType}/{id} Delete = DELETE
https://example.com/path/{resourceType}/{id} Search = GET https://example.com/path/{resourceType}?
search parameters... History = GET
https://example.com/path/{resourceType}/{id}/_history Transaction = POST https://example.com/path/ (POST a
tranasction bundle to the system) Operation = GET
https://example.com/path/{resourceType}/{id}/${opname}
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Creating a resource
POST {some base path}/Patient HTTP/1.1Authorization: Bearer 37CC0B0E-C15B-4578-9AC1-D83DCED2B2F9Accept: application/json+fhirContent-Type: application/json+fhirContent-Length: 1198
{ "resourceType": "Patient", ...}
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Server Response
HTTP/1.1 201 CreatedContent-Length: 161Content-Type: application/json+fhirDate: Mon, 18 Aug 2014 01:43:30 GMTETag: "1"Location: http://example.com/Patient/347
{ "resourceType": "OperationOutcome", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">The operation was successful</div>" }}
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Server Failure
HTTP/1.1 422 Unprocessable EntityContent-Length: 161Content-Type: application/json+fhirDate: Mon, 18 Aug 2014 01:43:30 GMT { "resourceType": "OperationOutcome", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">MRN conflict - the MRN 123456 is already assigned to a different patient</div>" },}
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Reading a Resource
GET /Patient/347?_format=xml HTTP/1.1Host: example.comAccept: application/xml+fhirCache-Control: no-cache
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Read response
HTTP/1.1 200 OKContent-Length: 729Content-Type: application/xml+fhirLast-Modified: Sun, 17 Aug 2014 15:43:30 GMTETag: "1" <?xml version="1.0" encoding="UTF-8"?><Patient xmlns="http://hl7.org/fhir"> <id value="347"/> <meta> <versionId value="1"/> <lastUpdated value="2014-08-18T01:43:30Z"/> </meta> <!-- content as shown above for patient --> </Patient>
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Search Request
GET https://example.com/path/{resourceType}?criteria
GET [base]/MedicationPrescription?patient=347
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{ "resourceType": "Bundle", "id" : "eceb4882-5c7e-4ca4-af62-995dfb8cef01" "meta" : { "lastUpdated" : "2014-08-19T15:43:30Z" }, "type" : "searchSet", "base": "http://example.com/base", "total": "3", "link": [ { "relation" : "next", "url" : "https://example.com/base/MedicationPrescription?patient=347&searchId=ff15fd40-ff71-4b48-b366-09c706bed9d0&page=2" }, { "relation" : "self", "url" : "https://example.com/base/MedicationPrescription?patient=347" } ], "entry": [ { "resource" : { "resourceType": "MedicationPrescription", "id" : "3123", "meta" : { "versionId" : "1", "lastUpdated" : "2014-08-16T05:31:17Z" }, ... content of resource ... }, }, ... 2 additional resources .... ]}
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"entry": [ { "resource" : { "resourceType": "MedicationPrescription", "id" : "3123", "meta" : { "versionId" : "1", "lastUpdated" : "2014-08-16T05:31:17Z" }, ... content of resource ... }, }, ... 2 additional resources .... ]}
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Update Request
PUT /Patient/347 HTTP/1.1Host: example.comContent-Type: application/json+fhirContent-Length: 1435Accept: application/json+fhir
{ "resourceType": "Patient", "id" : "347", "meta" : { "versionId" : "1", "lastUpdated" : "2014-08-18T01:43:30Z" }
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Update Response
HTTP/1.1 200 OKContent-Length: 161Content-Type: application/json+fhirDate: Mon, 18 Aug 2014 01:43:30 GMTETag: "2" { "resourceType": "OperationOutcome", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">The operation was successful</div>" }}
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Base Resource
{ "resourceType" : "X", "id" : "12", "meta" : { "versionId" : "12", "lastUpdated" : "2014-08-18T01:43:30Z", "profile" : ["http://example-consortium.org/fhir/profile/patient"], "security" : [{ "system" : "http://hl7.org/fhir/v3/ActCode", "code" : "EMP" }], "tag" : [{ "system" : "http://example.com/codes/workflow", "code" : "needs-review" }] }, "implicitRules" : "http://example-consortium.org/fhir/ehr-plugins", "language" : "X"}
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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
Administrative Patient, Practitioner,
Organization, Location, Coverage, Invoice
Clinical Concepts Allergy, Condition, Family
History, Care Plan Infrastructure
Document, Message, Profile, Conformance
Non-examples
Gender Too small
Electronic Health Record Too big
Blood Pressure Too specific
Intervention Too broad
25100-150 total
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DSTU Resource List
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Human Readable Summary
Standard Data Content: MRN Name Gender Date of Birth Provider
Extension with reference to its definition
Identity & Metadata
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Resource Documentation
For each Resource: Scope and Usage Notes Resource Content (UML and XML) Terminology Bindings Constraints Implementation Issues Search Parameters Examples, Profiles, Formal Definitions Mappings to RIM, CDA, v2, etc
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Resource Definitions
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Resource Definitions
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Resource Definitions
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Resource Definitions
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Example Resource Definitions
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Web of resources
Lab
Report
Related
Person
Patient
Practitioner
Location
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References
Resources are independent – don’t need to other resources to correctly interpret a resource
But resources reference each other extensively to form a web of information
Need to resolve references to fully understand the data
Reference is relative to server base URL<Procedure xmlns="http://hl7.org/fhir"> <subject> <reference value="Patient/23"/> </subject> …
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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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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
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FHIR EXTENSIONS
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Problems we face
No central authorities Permutation of biological and sociological
complexity Fractal use cases Economics favours balkinization Externalizing complexity Much confusion about the problem
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© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
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Sources of Complexity
Inherent in problem & description
business variability between instances
incompetence / inappropriate solutions
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Complexity ModelD
iffic
ulty
(lo
g)
Semantic Depth
HTTP / HTML
XML
WS
HL7 v2
Snomed
CDA
HL7 V3
openEHR
How?
Text
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Three Laws of Interoperability
1. Interoperability: It’s all about the people
2. You can hide the complexity, or make it worse, but you can’t make it go away
3. Cheap, flexible, and interoperable: when developing healthcare software, you can have two of these
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The Case for Extensions
Extensions are a problem Engineering – not handled by CASE Poorly described and carelessly done W3C rules: must interoperate without
extensions This is not possible in healthcare
Choice – design for absolutely everything or allow extensions
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Extensions
FHIR has a standard extension framework 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
All extensions are valid by schema etc.
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No pain…
Extensions are built into the wire format & handled by CASE tools
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 – only 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> …
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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 .
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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
There’s 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 themselves “FHIR Conformant”, a system must publish a Conformance instance
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StructureDefinition
Document how a resource structure What is has in it How it’s used
Aka Profile, Template, Clinical Model Defined as a resource (defines itself) Provided as part of the spec
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Profile (cont’d)
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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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Value sets
A list of codes Define your own, include codes from other code
system (e.g. LOINC) Used to define conformance rules, UI
functionality, system capabilities Functional service built around this
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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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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 Publicly available test servers Starter APIs published with spec
C#, Java, Pascal, ObjectiveC – more to come Connectathons to verify specification approaches Instances you can read and understand Lots of examples (and they’re valid too)
using HL7.Fhir.Instance.Model;using HL7.Fhir.Instance.Parsers;using HL7.Fhir.Instance.Support;
XmlReader xr = XmlReader.Create(
new StreamReadIFhirReader r = new XmlFhirReader
// JsonTextReader jr = new JsonTe// new StreamRead// IFhirReader r = new JsonFhirRe
ErrorList errors = new ErrorList(LabReport rep = (LabReport)ResourAssert.IsTrue(errors.Count() == 0
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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 understand and use
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Web technologies
Instances shared using XML & JSON Web calls work the same way they do for
Facebook & Twitter Rely on HTTPS, OAuth, etc. for security
functions
http://...
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Human Readable
Clinical Documents has both narrative and data
The data / narrative dynamic exists throughout the process
In FHIR, every resource is required to have 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 & 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
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IMPLEMENTING FHIR
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Documents
Similar to CDA Collection of resources bound together
Root is a “Composition” resource Just like CDA header
Sent as a bundle One context Can be signed, authenticated, etc.
Documents
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Messages
Similar to v2 and v3 messaging Also a collection of resources as a bundle Allows request/response behavior with
bundles for both request and response Event-driven
E.g. Send lab order, get back result Can be asynchronous Messages
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Service Oriented Architecture (SOA)
Do whatever you like (based on SOA principles) Ultra complex workflows Ultra simple workflows Individual resources or collections Use HTTP or use something else Only constraint is that you’re passing around FHIR
resources in some shape or manner
Services
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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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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) Mobile Applications
NearTerm
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Architecture
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_testing
Connectathons79
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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 I do recommend to read the specification 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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© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
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…82
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
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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© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
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
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
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Today / Tomorrow
Versions for today/tomorrow: FHIR is a rolling target right now (>100
commits/day) Server: http://fhir-dev.healthintersections.com.au/open
Stable version of spec: http://fhir-dev.healthintersections.com.au/index.html
HAPI: http://fhirtest.uhn.ca/baseDstu2/
.Net RI: https://www.nuget.org/packages/Hl7.Fhir/0.11.1-alpha4
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