JohnMoehrke PHR FHIR API, published by John Moehrke (himself). This guide is not an authorized publication; it is the continuous build for version 0.5.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/JohnMoehrke/phr/ and changes regularly. See the Directory of published versions

Oracle Health Comparison

This page includes an analysis of the Oracle Health (OH) FHIR support of the same health concepts delivered here from Vista. This section is based on sample data, Oracle Health FHIR documentation, and discussions with Oracle Health contacts.

The following tables have the following columns:

• MHV PHR – this represents what the MHV Legacy extracts and preserves for BlueButton. The element names in the MHV database are given.
• MHV FHIR – this represents that which is specified in this Implementation Guide
• va.gov UI – this represents the portion of the MHV FHIR that is extracted for use in the UI. This is determined by code inspection at a given time. (mostly from vets-website/src/applications/mhv-medical-records/reducers)
• FHIR us-core – this is indicating the specification in FHIR us-core. This is a set of requirements defined in the USA as core. Both MHV FHIR and Oracle Health follow this specification, so it should be seen as 'the gold standard'.
• OH FHIR – this is representing the FHIR population from Oracle Health (OH). This is based on the Oracle Health FHIR documentation, experimentation with B1930, and conversations with OH experts assigned to help us.
• Note – general notes, usually about OH

Where notes are more complex, especially those that would not fit nicely into the tables, there are sub sections with notes

General

Features that MHV provides today with Vista

• Single place to get all data
• hold data for a defined window (usually 36 hours)

When OH is added as a data feed. Where will duplicate data be detected and removed? OH does not provide clear provenance on the data they import from Vista.

Architectural Questions

1. Should va.gov go direct to OH. That is to not have MHV backend involved at all.
   1. va.gov will need to implement business rules for hold.
2. Should MHV backend implement a thin proxy with no persistence?
   1. MHV backend could implement hold.
3. Should MHV prefetch the OH data and place it in the same FHIR database?

implementation differences at element level or datatype level

This section contains any generalizable observations and concerns.

CodeableConcept

Note that some of the va.gov handling does do this processing this way. hence why I indicate it as medium impact.

Note 1: OH example

"code": {
          "coding": [
            {
              "system": "http://snomed.info/sct",
              "code": "735971005",
              "display": "Fish (substance)"
            }
          ],
          "text": "Fish"
        },

Encounter / Location

A common data need our MHV / va.gov User Interface (UI) has is to show where the data was gathered. In Vista this is a field of the main datatype, where as in OH this would be found in a related Encounter.

De-Duplication

With Vista data, we preserve any source (Vista) id values in the Resource.identifier.

With OH, they do not preserve the source (Vista) id values. They do however create an Encounter resource that stands for the data import act. Thus all data that was imported from Vista, will have the same Encounter. (Would like to get an example of this)

This presents a big problem with de-duplication, and will be a struggle for us to not show the patient the same data as maintained in original Vista and as replicated into OH.

AllergyIntolerance

Conditions

Conditions va.gov concern

• clinicalStatus is important, especially for OH, and especially when they are resolved.
• MHV FHIR will just be problems, but OH will add encounter diagnosis and health concerns. These might be expected, but might not

Immunization

Note 1: OH example

"vaccineCode": {
          "coding": [
            {
              "system": "https://fhir.cerner.com/d45741b3-8335-463d-ab16-8c5f0bcf78ed/codeSet/72",
              "code": "4145940",
              "display": "tetanus, diphtheria, acellular pertussis",
              "userSelected": true
            },
            {
              "system": "http://hl7.org/fhir/sid/cvx",
              "code": "115",
              "display": "tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine, adsorbed",
              "userSelected": false
            }
          ],
          "text": "tetanus, diphtheria, acellular pertussis"
        }

Note 2: OH example

"protocolApplied": [
          {
            "targetDisease": [
              {
                "coding": [
                  {
                    "system": "https://fhir.cerner.com/d45741b3-8335-463d-ab16-8c5f0bcf78ed/codeSet/4003106",
                    "code": "42348063",
                    "display": "TD/TDAP",
                    "userSelected": true
                  }
                ],
                "text": "TD/TDAP"
              }
            ],
            "doseNumberString": "Unknown"
          }
        ]

Note 3: OH location

• Confirmed from OH that the location is preferable to navigating thru the encounter to the encounter location.

Immunizations va.gov concern

• Immunization manufacture is never populated by MHV FHIR; as VIA never gives the value to us even if it is recorded in Vista.
• Immunization reaction is never populated (Note that KBS also discourages using the vista reaction, but we are using it for historic reasons)

Notes (DocumentReference)

Notes on Vista

• Consultation Note (11488-4)
• Progress note (11506-3)
• Discharge Summary (18842-5)

may have a CPT code

Notes on VA.Gov handling

• don't assume code has display
• don't assume .text is populated
• don't assume resources are contained
• don't assume attachment.data
• attachment must be retrieved from URL
• don't assume text
• not going to find attending in text body
• Search is limited to codes
  • PHYSICIAN_PROCEDURE_NOTE = '11506-3' # Physician procedure note
  • DISCHARGE_SUMMARY = '18842-5' # Discharge summary
  • CONSULT_RESULT = '11488-4' # Consultation note
  • Should be using category clinical-note

Notes on OH

• will not have a signed date/time, OH says to use the lastUpdated date/time (Later said use attachment.creation)
  • Signature dateTime, using lastUpdated (or creation), may result in data getting "held" a second time
• Note that period may have start or end; or both. So need to be robust.
• not likely able to find the attending in the text body
• attachment mime-types - pdf, text, richtext, rtf, html, xml, xhtml
• unclear if $docref operation might be useful
• TODO: need to analyze B1930 samples relative to va.gov expectations.
• https://wiki.cerner.com/display/public/reference/Understand+R4+DocumentReference+Resource+Cerner+Millennium+Mappings
• What does an AVS look like in the OH FHIR api? Is there an B1930 example?

Vitals (Observation)

FHIR us-core has constrained Vitals very well, so the difference is not much. Although OH FHIR indicates it supports other elements, this is a general statement about Observation. They don't have a Vitals specific listing.

Vitals on va.gov

• search for only
  • BLOOD_PRESSURE = '85354-9' # Blood Pressure
  • BREATHING_RATE = '9279-1' # Breathing Rate
  • HEART_RATE = '8867-4' # Heart Rate
  • HEIGHT = '8302-2' # Height
  • TEMPERATURE = '8310-5' # Temperature
  • WEIGHT = '29463-7' # Weight
• should search on vital-signs category

OH

https://wiki.cerner.com/display/public/reference/Understand+R4+Observation+Resource+Cerner+Millennium+Mappings

Labs

Labs are handled very differently between MHV FHIR and OH FHIR. Where MHV FHIR is organized around a DiagnosticReport, OH has no DiagnosticReport. The MHV FHIR use of DiagnosticReport reflects the way the data are organized in Vista and the way they are organized as they are passed to MHV, where the only clear identifier MHV has is the DiagnosticReport identifier. MHV FHIR has Observations, but they are contained in the DiagnosticReport as that is all we can track and de-duplicate based on. This is not surprising as with Chem-Hem there is no presentedForm, so there is no overall report text.

Vista Chem-Hem

Vista Microbiology Labs

Vista Pathology Labs

Note it is uncommon for Observations on Pathology.

Lab va.gov notes

• today only handle Observation.valueQuantity. Where you might get valueString and with OH get valueCodeableConcept.
• Chem-Hem seem to be concat all the elements of the Observation into one string.
• does not look for Observations on Microbiology (similar with Pathology, but it is unusual to have Observations with Pathology)
• Pathology is handled different in US-Core and OH from current MHV-FHIR. Pathology is a DiagnosticReport for Report and Note Exchange, not Laboratory.
  • va.gov should be looking for .category laboratory, and not at the .code. OH has much more specific and propritary code values.

OH Labs

Oracle-Health focuses on the Observation resource, these would be grouped Observation.basedOn by a ServiceRequest (order). There might be a DiagnosticReport if there is a presented form. We might need to navigate to the Encounter to get some physical location specifics. ServiceRequest.category will have a defined code for laboratory, but OH does not support search by .category; thus one must search by .code.

1. Find Laboratory ServiceRequest
   1. Search for ServiceRequest for this Patient. This gives ALL of the ServiceRequests available, which may include many things beyond Labs

   2. Search within the Bundle results for category = {codeSystem-6000}

      2513 "Laboratory"

   3. continue for each ServiceRequest of interest
2. Search for Observation that have Observation.basedOn of a ServiceRequest of interest
3. Search on DiagnosticReport that have DiagnosticReport.basedOn of a ServiceRequest of interest
4. Search on DocumentReference that have DocumentReference.basedOn of a ServiceRequest of interest
5. Get Encounter indicated by ServiceRequest.encounter

if doing searches only for updated information, then search for Observation with a category of laboratory that have changed (lastUpdated) since the last time. From this, look if there is an updated DocumentReference or DiagnosticReport.

If MHV is going to proxy copy the FHIR data from OH; then we could use the ServiceRequest.category to make the above much more efficient. We can make ServiceRequest.category searchable, and support _revInclude on the Observations, DiagnosticReport, and DocumentReference.

Hold time:

• status goes to authenticated (? final=authenticated)
• use last updated as that date/time
• Note that hold time will reset if there is any reason for the lastUpdated to be changed after signature. Like something getting corrected in the ServiceRequest.

Notes:

• DiagnosticReport.conclusionCode, if populated, would be the normalcy code (codeset 52) on the clinical event table (e.g. normal, abnormal, high, critical, etc)
• OH does not support the Specimen resource. How are specimen tracked? Specifically tracking when the specimen is obtained.
  • Did not get a clear answer
• ServiceRequest search must start with a very openended search, thus exposing us to far more data than we need, thus presenting a performance concern
• Signature dateTime, using lastUpdated, may result in data getting "held" a second time
• There is no dateTime or location for specimen taking.

OH documentation CernerWiki

• Microbiology Labs - microbiology: bacteriology, virology, mycobacteriology, and parasitology.
• Anatomic Pathology - surgical pathology, autopsy, cytology, and bone marrow.
• General Laboratory - Oracle Health General Laboratory fully automates clinical, financial, and managerial processes associated with the chemistry, hematology, coagulation, urinalysis, immunology/serology, and toxicology sections of the clinical laboratory.
• https://wiki.cerner.com/display/public/reference/Understand+R4+Observation+Resource+Cerner+Millennium+Mappings
• https://wiki.cerner.com/display/public/reference/Understand+R4+DiagnosticReport+Resource+Cerner+Millennium+Mappings
• https://wiki.cerner.com/display/public/reference/Understand+R4+DocumentReference+Resource+Cerner+Millennium+Mappings
• https://wiki.cerner.com/display/public/reference/Understand+R4+ServiceRequest+Resource+Millennium+Platform+Mappings

Radiology Reports (DiagnosticReport)

Note: MHV FHIR will always be presentedForm using .data and text, OH often has multiple presentedForm (pdf, xml), using .url to Binary

Radiology OH

• DiagnosticReport and DocumentReference are both used. DiagnosticReport seems like the more likely, but OH indicated DocumentReference can be used (unclear).
• Search for ServiceRequest as above for laboratory orders; filter those to
  • ServiceRequest.category = 2517 for Radiology
  • ServiceRequest.category = 4326086 for Cardiology from CVIM
  • ServiceRequest.category = 636062 for non-CV Cardiology
• DICOM will still come from CVIX
• Where do we look for the site organization or location? Or is this in the Encounter or ServiceRequest? –> Yes both might need to be used. First try ServiceRequest, second use Encounter.
• B1930 has some DiagnosticReport and some DocumentReference –> yes both.
• What is the evidence of a signed Radiology Report? –> status is set ot Verify, and time signed is the DocumentReference.content.attachment.creation. This gets updated each time the report is signed or modified, thus it is a sliding date that may produce non-desirable results.
• There is a linkage to the images in VIX/CVIX/CCIA. –> Using event id and a URL. –? Need more detail.

Questions:

• Is effective always DateTime or could it be Period?
• With a Radiology Report, will the .result ever hold Observations? (us-core MS) None seen in B1930 examples.
• With a Radiology Report, will the .media.link ever be filled? (us-core MS) None seen in B1930 examples.
• With a Radiology Report, how is .conclusionCode used? None seen in B1930 examples.
• What does a CVIX managed Radiology Report look like? Is there B1930 example?

CodeSet 6000

The FHIR team reviewed the original information to filter based on code value on code set 200 for CATELOG_CD and have determined that those are for all the ordables in the domain.

ServiceRequest.Category which is part of code set 6000 and puts the order in a category.

• 20454826, AMB POC, Ambulatory POC
• 20460012, AMB PROC, Ambulatory Procedures
• 636727, ATD, Admit/Transfer/Discharge
• 636061, AUDIOLOGY, Audiology
• 4054100, BBDONOR, Blood Bank Donor
• 636062, CARDIOLOGY, Cardiology
• 4326086, CARDIOVASCUL, Cardiovascular
• 636063, CONSULTS, Consults
• 636064, DIALYSIS, Dialysis
• 636067, E & M, Evaluation and Management
• 636065, ENT, ENT
• 2513, GENERAL LAB, Laboratory
• 636069, INFECT CONTR, Infection Control
• 2515, NURS, Patient Care
• 636072, ORTHOPEDICS, Orthopedics
• 636075, PROCEDURES, Procedures
• 636076, PULMONARY, Pulmonary Medicine
• 2517, RADIOLOGY, Radiology
• 23276383, REFERRAL, Referral
• 636078, RESP THER, Respiratory Therapy
• 2519, SURGERY, Surgery
• 636082, UROLOGY, Urology
• 636084, WOMENS SVCS, Women's Services

Cardiology Reports (DiagnosticReport)

Today MHV/FHIR map these to DocumentReference, but also does not get these reports anymore. OH uses DiagnosticReport.

DiagnosticReport.category = LOINC#LP29708-2 "Cardiology"

• B1930 has some DiagnosticReport and some DocumentReference
• What does a signed Cardiology Report look like?

Imaging

DICOM will continue to be with CVIX.