Using FHIR to expose a Patient Identity Registry lookup service – part 2

In the previous post we discussed the use of the patient resource as part of an Identity registry service. In this post we will discuss the behavior of that service.

To review the specific scenarios we are supporting:

  1. Retrieving a list of matching patients based on criteria such as name, gender, Date of Birth and such like.
  2. If we do have an identifier, retrieving the resource (or resources) that have that identifier.

1. Searching for a patient

The first scenario is a simple search – as we have already discussed. We’ll support searching on name, gender and age. The spec gives the details of these search parameters.

Name is straightforward – it is a string and the spec states that the server will match our string with both family and given names which have that string within the name. The following GET request will return all patients with ‘eve’ in their name.

http://hl7connect.healthintersections.com.au/svc/fhir/patient?name=eve

Gender is a token. Reviewing the bindings for gender we see that the options are currently ‘M’, ‘F’ or ‘UN’, so the following GET request will return all males with ‘eve’ in their name

http://hl7connect.healthintersections.com.au/svc/fhir/patient?name=eve&gender=M

Age is a bit trickier. We could always use Date of Birth (and maybe we should) but often we’ll only know approximately how old a person is. For this to work we’re going to need modifiers on the query. I won’t describe the details (refer to the spec for that), but basically you can do things like specify before and after as shown in the example below for a child less that 3 years old (The users UI should be able to create dates from ages without difficulty).

http://hl7connect.healthintersections.com.au/svc/fhir/patient?birthdate:after=2010-01-01&birthdate:before=2013-12-31

Couple of notes:

  • I’ve used Grahames server rather than the elbonian example I used in the previous post so you can try it out for yourself.
  • Also, the last query actually returns an animal – at least it did when I tried it. FHIR supports veterinary as well as human health information.

Naturally the response for all of these examples will be a bundle of patient resources, as previously discussed.

2. Getting the details when the Identifier is known

So finding a patient by searching on name or other parameters is straightforward. What if we already know the identifier? We can just GET that patient resource, right?

Well, no we can’t. We still need to do a search, except that the parameter we are using is the identifier. If we stop to think about it for a second it is obvious why. We can only retrieve a resource directly if we know its ID – and therefore its URI. But the ID and the identifier are not the same (as we discussed in the last post) – so a search is needed, and we will get a bundle back – hopefully with only a single resource in it.

Try the following link:

http://hl7connect.healthintersections.com.au/svc/fhir/patient?identifier=444222222

When I tried this I got a couple of resources back – well it is only a test server. But – this does point out that FHIR does not enforce the ‘uniqueness’ of an identity – it is the responsibility of the application behind it that does that.

But there are still a couple  more things to consider.

  • First, depending on how we configure the server, we may or may not get inactive records back. Recall the merge example in the last post, where we merged WER4568 with PRP1660 – de-activating WER4568. What should we get back if we search for WER4568? It makes sense to still return the resource, but it does mean that we need to check the ‘active’ property when we get it to make sure it is still in use (and we can use the link property to get the resource to which it was merged if not).
  • We also need to think a bit about the details of the identifier search. It’s a token, so if we just search on the value, there’s a chance that the same identifier could exist in different namespaces. To be safe we need to specify the namespace as well as the value – thus the identifier parameter for PRP1660 becomes something like www.moh.elbonia.govt/nhi/PRP1660 rather than just PRP1660.

So we’ve got a REST service that allows us to query a patient identity service using simple GET requests and supporting a number of parameters.

What about Security & Privacy? We won’t consider these yet. They depend on a number of aspects of FHIR that we have yet to discuss such as tags and oAuth – we’ll revisit this topic when we’ve done that.

But we can create a conformance resource. This is a resource that can be used by both server and client – but we’ll just think about the server at the moment. The conformance resource allows a server to declare – in a computable way – what resources it supports, and what actions against those resources. Here is an example:


<Conformance xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="http://hl7.org/fhir">
   <text>
     <status value="generated"/>
     <div xmlns="http://www.w3.org/1999/xhtml">
       <p>This conformance statement id for the Patient Identity service for the Elbonian Ministry of Health</p>
       <p>The Registry supports the Read transactions for the resource Person.</p>
     </div>
   </text>

   <identifier value="68D043B5-9ECF-4559-A57A-396E0D452311"/>
   <version value=".1"/>
   <name value="Elbonian Patient Registry Conformance statement"/>
   <publisher value="Elbonian MOH"/>
   <telecom>
     <system value="email"/>
     <value value="wile@elbonia.govt"/>
   </telecom>
   <description value="This is the FHIR conformance statement describing the Patient Registry for the
     Elbonian Ministry Of Health.
     It allows a user to search on patients, and retrieve the details of a patient based on their identifier.
     No security is required as Elbonians do not have any concept of privacy"/>
   <date value="2012-10-14"/>
   <software>
     <name value="PatientRegister"/>
     <version value="0.34.76"/>
   </software>
   <fhirVersion value="0.12"/>
   <acceptUnknown value="false"/> <!--   this system does not accepts unknown content in the resources   -->

   <!--   this system can do either xml or json. (Listing both implies full support for either, with interconversion)   -->
   <format value="xml"/>
   <format value="json"/>
   <!-- We only support REST interfaces at this time -->
   <rest>
     <mode value="server"/>
     <resource>
       <type value="Patient"/>
       <operation>
         <code value="read"/>
       </operation>
       <searchParam>
         <name value="name"/>
         <type value="string"/>
         <documentation value="Lookup by patient name. Only active patients will be returned. All parts of the name are searched."/>
       </searchParam>
       <searchParam>
         <name value="identifier"/>
         <type value="token"/>
         <documentation value="Lookup by identifier. Both active and inactive patients will be returned."/>
       </searchParam>
       <searchParam>
         <name value="birthDate"/>
         <type value="date"/>
         <documentation value="Lookup by patient birts date. Supports the :before and :after modifiers to allow for age ranges"/>
       </searchParam>
     </resource>
   </rest>
 </Conformance>

The conformance resource allows a potential client to understand the capabilities – and requirements – of our Registry service. It should be self-explanatory, so I won’t go into it in much more detail. However conformance statements – and the associated concepts of profiles – are a lot more powerful than this, and will receive more attention in due course. In some ways, they are analogous to UDDI and WSDL in the SOAP world – but much easier to understand.

According to the spec the server should deliver this resource in two way:

  • GET [base]/metadata {?_format=[mime-type]}
  • OPTIONS [base] {?_format=[mime-type]}

Thus a GET to :

http://hl7connect.healthintersections.com.au/svc/fhir/metadata

will return the conformance statement for Grahames server, and hopefully you can imagine what the equivalent for the elbonian server would be.

(The reason why there are two ways is that while the GET method is pretty much universally supported by HTTP clients, the OPTIONS method is not.)

Well, that brings us to the end of this short series (2 posts) on FHIR-enabling a patient registry service. We now have a “simple to use” service that allows any user to search our patient registry using standard tools – either from the command line of as part of an application. We could easily extend it to support updates as well – perhaps when a patient changes address or contact details these updates could be applied directly using a PUT against the resource URI. If we did allow such a thing, then authentication and authorization become a lot more important – and we’d probably also want to have some sort of person mediated workflow and checking involved rather than just a direct update. But the point is we can do that if we choose to do so.

Although fairly high level, hopefully this gives a ‘real-world’ example of where FHIR can add real benefit in health interoperability, as correctly identifying the patient is the cornerstone of accurately recording health information.

Next post will be back to basics – the codeableconcept datatype deserves some attention…

About David Hay
I'm a Product Strategist at Orion Health, Chair emeritus of HL7 New Zealand and co-Chair of the FHIR Management Group. I have a keen interest in health IT, especially health interoperability with HL7 and the new FHIR standard.

8 Responses to Using FHIR to expose a Patient Identity Registry lookup service – part 2

  1. FHIR Starter says:

    Nice examples but surely an NHI is a pipe dream almost anywhere in the world except Elbonia.

    What you describe for such a service seems fairly effortless, but could you do something like a Google-style suggestions search with functions like these?

    It’s good to see that there’s a data model behind the resources. How are you producing the UML diagrams – eg http://www.hl7.org/implement/standards/fhir/patient.html#uml – are they hand drawn?

    Keep posting.

    • David Hay says:

      Yeah – hard to imagine a country having the foresight to set up a national identity service (Don’t discourage the Elbonians though…)

      The UML diagrams are all created automatically during the build process. Grahame sweated blood to get that working. All the FHIR artifacts are produced automatically – one of the reasons why the quality is so high. And the examples are also all checked against their schema at the same time…

      wrt Google style suggestions – that’s an interesting one. I don’t think the current spec supports that type of searching, but there’s nothing to stop someone creating a service to do that. I can see a few issues though…

    • In Canada, we have provincial-level identifiers and registries. (With an architecture that calls for them to be federated – eventually.)

      It’s possible to define custom search parameters, so a Google-like search would be possible, though as a rule that sort of openness would raise privacy issues galore. For that reason, difficult to imagine it being wide-spread enough to be part of the core spec.

  2. FHIR Starter says:

    Good point – perhaps an address lookup service would have been a better example. Or a terminology service. I’m looking forward to hearing about terminology and coded data elements in a future post.

    But first a quick question. FHIR so far seems to be about the API and about well-defined resources and representations, but there has to be a database behind there somewhere and I’m wondering how much FHIR has to say about that, if anything. For example, is it possible to define integrity rules over data held by a FHIR server? How could I implement a business rule such as an NHI number can’t be assigned to more than one patient concurrently?

    • Generally, FHIR doesn’t tend to define rules like that – it just makes it clear that the data managers can. The reason is that we define what we can standardise, and enterprise/business types tend not to tolerate standardising this stuff very well.

  3. Pingback: Using FHIR to expose a Patient Identity Registry lookup service – part 1 | Hay on FHIR

  4. Stephan says:

    It’s really a great and useful piece of info.
    I am happy that you just shared this helpful info
    with us. Please keep us informed like this.
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  5. Pingback: FHIR and XDS – Submitting a document from a Document Source | Hay on FHIR

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