MyHealtheVet PHR FHIR API, published by VA Digital Services. This guide is not an authorized publication; it is the continuous build for version 0.3.9-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/department-of-veterans-affairs/mhv-fhir-phr-mapping/ 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

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 diagnostis 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"
          }
        ]

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.

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
• not likely able to find the attending in the text body
• discharge summary may not be as transparent?
• unclear if $docref operation might be useful
• TODO: need to analyze B1930 samples relative to va.gov expectations.

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

Chem-Hem Labs

Chem-Hem is 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. Thus 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.

MHV FHIR

chem-hem va.gov notes

• today only handle Observation.valueQuantity. Where you might get valueString and with OH get valueCodeableConcept.
• seem to be concat all the elements of the Observation into one string.

chem-hem OH Notes

It does not appear that OH uses a DiagnosticReport for Chem-Hem results (e.g. any labs not Pathology, Microbiology, Radiology, or Cardiology). Might be handled purely by searching on Observations of type laboratory.

From OH 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.

• What is the recommended way to find all Observations that are related to non pathology or microbiology labs?
• OH does not support the Specimen resource. How are specimen tracked? Specifically tracking when the specimen is obtained.

Microbiology Labs

Microbiology is not yet implemented in va.gov

Microbiology OH

B1930 has DiagnosticReport for Microbiology, but response from OH seems to indicate that this would not be the case. Might just be a miscommunication, that OH was just stressing that Microbiology also uses Observations.

OH CernerWiki on Microbiology Labs - microbiology: bacteriology, virology, mycobacteriology, and parasitology.

Grouped orders can be recognized with the same ServiceRequest in the Observation.basedOn

Pathology Labs

Pathology is not yet implemented in va.gov

Pathology OH

The pattern on the general OH FHIR site is general for Labs. Unclear yet how this is specialized in the real-world for pathology.

OH on Anatomic Pathology - surgical pathology, autopsy, cytology, and bone marrow.

• OH use encounter and ServiceRequest.
• .conclusionCode, if populated, would be the normalcy code (codeset 52) on the clinical event table (e.g. normal, abnormal, high, critical, etc)

Radiology Reports (DiagnosticReport)

Radiology OH Questions

• Is effective always DateTime or could it be Period?
• Where do we look for the lab organization or location? Or is this in the Encounter or ServiceRequest?
• 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.
• B1930 has some DiagnosticReport and some DocumentReference
• What is the evidence of a signed Radiology Report?

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