PH eReferral Implementation Guide
0.3.0-draft - draft Philippines

PH eReferral Implementation Guide, published by UP Manila SILab. This guide is not an authorized publication; it is the continuous build for version 0.3.0-draft built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/jgsuess/ph-ereferral/ and changes regularly. See the Directory of published versions

Ig Evolution

IG Evolution: From Agile Draft to HL7 Standard

An Implementation Guide does not emerge complete. It evolves — first rapidly and informally, then more deliberately and with formal governance as it matures. Understanding that evolution helps teams invest the right energy at each stage: moving quickly when the goal is to produce something evaluable, then slowing down to build evidence when the goal is to produce something durable.

Two Phases of IG Development

IG development naturally falls into two broad phases, each with a distinct purpose and operating rhythm.

IG Evolution — Agile Draft Phase to HL7 Formal ProcessIG Evolution — Agile Draft Phase to HL7 Formal ProcessFMM 0 — breaking changesexpected and welcomedCI Build — Initial DraftAgile iteration across SMART layers L1-L5Publish to /dev/ for stakeholder reviewCollect and incorporate feedbackyesEvaluation-ready?noTag draft releaseAssess readiness:• Semantic stability?• Pilot implementations?• Stakeholder consensus?• Clean CI build?Engage HL7 Work GroupConnectathon / interoperability test(≥ 3 independent systems — FMM 2)File Draft or STU BallotBallot cycle(collect comments → reconcile negatives)STU publication (FMM 3-4)Gather production implementation evidenceyesFMM 5 evidence reached?noNormative Ballot (WG + FMG + TSC)Normative Publication — specification locked"Phase 1 — Agile Draft""Transition — Readiness Gate""Phase 2 — HL7 Formal Process"

Phase 1 — Agile Draft

The early life of an IG is best served by a rapid, iterative process. The goal is not a polished specification but something concrete enough to evaluate: a working, published guide with realistic examples that stakeholders can read, query, and critique.

Short cycles through the WHO SMART Guideline layers (L1–L5) — as described on the Approach page — allow the team to surface ambiguities early, incorporate domain-expert feedback, and converge on a model that reflects real-world practice. At this stage:

  • The IG is published as a CI build (/dev/) after every push to main.
  • Breaking changes are expected and welcomed — each iteration tightens the artefacts rather than locking them prematurely.
  • Stakeholder reviews are based on concrete examples, not abstract specifications, making it easier to spot misunderstandings and missing elements.
  • Feedback is captured as scoped items for the following iteration, keeping the loop short and focused.

This is where the PH eReferral IG currently stands.

When Is a Draft Ready to Graduate?

The transition from Phase 1 to Phase 2 is not triggered by a calendar date or a version number. It is triggered by evidence of stability and stakeholder alignment:

Signal What to look for
Semantic stability Iterations produce clarifications and refinements, not fundamental redesigns
Stakeholder consensus Domain experts, clinicians, and implementers agree the model reflects real-world practice
Pilot implementation At least one system has consumed or produced examples, even in a test environment
Tooling maturity The IG builds cleanly, examples validate, and the CI pipeline is reliable

When these signals converge, the project is ready to engage with a broader process — one designed to test the IG against a wider community and produce a specification stable enough to build on.

Phase 2 — HL7 Formal Process

Once the draft IG is sufficiently stable, the operating rhythm changes. Iterations slow down; governance becomes more structured; and the reviewer community expands well beyond the core project team.

At this stage, HL7 International offers a well-established framework for advancing the IG through successive maturity levels. The framework includes:

  • A naming convention for each stage of the lifecycle** — from Draft through Standard for Trial Use (STU) to Normative — so that every published version carries an unambiguous signal about its stability and change tolerance.
  • A FHIR Maturity Model (FMM) that defines objective, evidence-based criteria for each stage transition. Moving up the FMM requires documented interoperability testing, demonstrated implementations, and formal review results — not just author judgement.
  • Ballot and governance processes that route the IG through HL7 Work Groups, the FHIR Management Group (FMG), and, for Normative publications, the Technical Steering Committee (TSC).

The HL7 process is not a replacement for agile thinking; it adds governance checkpoints that ensure each stage transition is evidence-based and community-validated.

What Changes in Phase 2?

Moving into the HL7 formal process introduces practices that are not needed — and would be counterproductive — during the rapid draft phase:

Practice Phase 1 — Agile Draft Phase 2 — HL7 Formal
Iteration speed Rapid (days to weeks) Slower (months per ballot cycle)
Breaking changes Expected and welcomed Progressively restricted
Reviewers Core team + domain experts HL7 work groups, independent implementers
Interoperability testing Informal demos and pilots Formal Connectathon evidence (≥ 3 systems)
Publication CI build + tagged draft releases Formal HL7 publications with ballot status
Governance Project team decision HL7 WG + FMG + TSC approval chain

The transition is gradual rather than abrupt. A team may begin engaging with HL7 Work Groups and conducting interoperability tests while still iterating on content — the formal ballot submission is the point of no return, not the first conversation.

The PH eReferral IG on the Evolution Path

This IG is currently in Phase 1. The agile approach described on the Approach page is the right tool for this stage — it produces working, evaluated content quickly and keeps the cost of change low.

When the IG reaches evaluation readiness, the natural next steps are:

  1. Engage with the relevant HL7 Work Group (e.g. through HL7 Philippines or an affiliate).
  2. Conduct a Connectathon or equivalent interoperability test with ≥ 3 independent systems.
  3. File a Draft Ballot or STU Ballot, depending on the FMM level reached.
  4. Progress through STU releases based on accumulated implementation evidence.

The HL7 framework provides a proven path from a well-evaluated draft to a published standard. The agile phase builds the foundation that makes that path navigable.

For the full detail of each HL7 stage, the FHIR Maturity Model, and the evidence required at each transition, see the HL7 Standards Lifecycle page.

For the CI-based automated testing approach that supports Phase 2 adoption, see Interoperability Matrix Testing.