Clinical Scenarios in FHIR

As you know (or should by now!), FHIR has from the outset been an implementer driven standard. The focus has always been on making healthcare interoperability as straightforward as possible, and regular connecathons have been an important part of that process (and we’re up to our 7th now).

However, it has to be admitted that thus far it has been the ‘techies’ – the ‘geeks’ – that are the main attenders at connectathon – and that’s kind of inevitable, given all the base work that’s needed to make FHIR a realistic standard for exchanging health information.

But FHIR is all about exchanging clinical information, and that means that it has to meet the needs of clinicians (which I use in the widest sense) as well as the technical folk. (And patients too – though that is another story).

At the last Working Group Meeting in Phoenix, we decided that it was time to think about a ‘Clinical Connectathon’ – where the emphasis was on meeting the needs of clinicians delivering care rather than the needs of technical people supporting them – can FHIR  do that?

So, at this WGM in September (held in Chicago) we’re going to have our first Clinical Connectathon (as well as the usual one – sigh). The focus of this event is to allow clinicians to focus on the “clinician to clinician connection” rather then the underlying technical resources that support those interactions.

We’ve  asked the Patient Care workgroup to come up with a set of representative scenarios that we can use. The idea is that we will develop a simple FHIR based application that can support  these scenarios and use that to get feedback from the clinicians.

This will be a pilot with a small number of attendees – if all goes well then they can become a regular feature of Working Group Meetings.

They’ve done that, so our task now is to take those scenarios and decide if we have the FHIR resources to support them. The scenarios are listed on a page off the Patient Care wiki and I’m going to take a look at one of those scenarios – the chronic care scenario to see if we have defined the resources required to meet it.

In the section below, I’ve extracted the text from the scenario and placed my comments as indented sections in-line. I hope that makes sense!

Chronic Care Scenario

Trigger

Mr Bob Anyman presents at his PCP clinic for review of his blood glucose profile and further assessment of his chief complaints

Flow of Events

1. Dr. Patricia Primary reviews Mr. Anyman’s presenting complaints, the fasting blood glucose and oral glucose tolerance test results and concludes the patient suffers from Type II Diabetes Mellitus (Type II DM).

So we’ve got a Practitioner resource (Dr. Patricia Primary), an Patient resource (Mr. Anyman’s), some presenting complaints (Observations) and a condition (Condition)

2. Documentation in EMR:

  • Chief complaints = general fatigue; polydipsia; polyuria; episodes of headache, sweating, trembling, confusion; cold feet with decreased sensation
  • Fasting blood glucose = 8.9 mmol/L
  • OGTT 2 hours after 75 gm glucose load = 15.2 mmol/L
  • Diagnosis = Type II DM

Presumably this relates to the current consultation. So we’re going to need an Encounter to represent the details of the consultation (date, time, participants, location and so forth). There are a number of complaints that can be represented as Observations (and linked to the Encounter), a fasting blood glucose and OGTT  (these must have been done earlier so will be DiagnosticReport resources) and a diagnosis.

 The diagnosis is interesting. Not quite sure about the best way to represent this – It’s a Condition for sure, but it needs to be linked to the Encounter.  Condition does have an ‘encounter when first asserted’, but that might not be the best option here. Perhaps an extension on encounter called ‘diagnosis’ that references a Condition resource might be the best option here. (But if we do that, we probably want a List resource to represent the current ‘problem list’ – see the next step)

 3. Dr Primary also reviews the patient’s medical history and identifies that he also has hypercholesterolemia and hypertension

 Well, no real problem here. These are existing Conditions for the patient. We might want to think about a List resource to represent the ‘current problem list’ that references these resources as this will give us a tidy ‘snapshot’ of the problem list and allow us to represent changes over time.

4. The medication management record reveals that the patient is quite often non-compliant in taking his anti-hypertensive and cholesterol lowering medications

 This ones a bit tricky – how to we actually know that the patient is non-compliant with medications? If we have access to dispensing records (ie MediationDispense resources  then we could figure it out. It’s most unlikely that we have details of actual administration records (in an inpatient setting yes, but in ambulatory care?). Might take a pass on this one.

5. Dr Primary performed a physical measurement assessment. The results indicate that Mr Anyman is also overweight:

  • Height = 170 cm
  • Weight = 98 kg
  • BMI = 33 (30+ = obese)

Easy. Observations that reference the encounter. (We will need an extension to do this – but that’s no problem).

6. Dr Primary discusses with the patient the potential serious health risks (cardiovascular and neurovascular).

Well – it’s just a discussion – perhaps the notes will contain an observation that refers to the encounter using the same extension as we used above (And this is kind of interesting – we’re staring to want to link observations to encounters – at the least we want a standard HL7 extension – maybe it even warrants a new core property to the Observation resource?)

6a. The patient agrees to have a DM care plan drawn up to include the following:

Ok a CarePlan is needed. We do have a number of options here – for example do we have a single care plan for the patient with everything in it, or a separate plan for each condition? My preference is for the latter, but FHIR allows for either

 The rest of the post are the detailed parts of the plan.

 

6a-1 Health Concern/Problem 1 = inability to maintain effective glycaemic control

Goal 1 = achieve glycaemic control – aiming at fasting blood glucose level to 3.0 – 5.5 mmol/L; HbA1c below 6%

Intervention:

Medication = metformin extended release: begins with 1000mg taken with evening meal (and reviewed weekly for dose titration to no more than 2500mg/day) [Mayo clinic protocol]

A prescription was also generated for the patient

Exercise: refer to exercise physiologist to develop a weight reduction plan optimised for glycaemic control

Diet: refer to dietitian to develop a diabetic nutrition plan optimised for glycaemic control

There’s a few things here. The goal is part of the careplan already (though an extension to hold the specific metrics of blood glucose and HbA1c are probably needed (need to think about the details of these – but that’s for a later post!). The goal can refer to the Diabetes Concern, so no issues there.

The medication intervention is straightforward – that’s an activity where the detail points to a MedicationPrescription (a wee bit more complex than your usual one, but within the capability of FHIR).

The prescription is actually modeled in FHIR as an order (that references the MedicationPrescription)

Then a referral to physiologist & dietitian? Well, the Patient  Care workgroup is defining that, so we can assume it will meet the requirements!

6a -2 Health Concern/Problem/need 2 = need to adhere to an optimised diabetic diet for effective glycaemic and weight control

Goal 2 = conformance to optimise diabetic diet (in conjunction with exercise plan to achieve glycaemic and weight control)

Intervention: refer to dietitian for Type II DM diet plan – goal weight of 72 KG to reach a BMI of 25, controlled carbohydrate, high fiber (30 grams per day), low saturated fat, low sodium (less than 2000 mg per day)

This is another careplan (assuming that we’re using separate plans). If we need to code the specific details of the goal then we can use extensions – or just refer to it as text (and let’s face it, this how most EMR systems would do that these days).

And a dietitions referral? Already done one of those… (though this does suggest that we want a reference from a referral back to one or more careplans.

 6a-3 Health Concern/Problem 3 = obesity compromising effective glycaemic, cholesterol and blood pressure control

Goal 3 = conformance to weight loss program (in conjunction with diet plan): aim at 5-10% weight reduction in first 6 months taking the weight down to 90kg (BMI = 31); thereafter maintain weight and if possible further reduce weight by another 5%

Intervention: refer to exercise physiologist for supervised Type II DM and weight loss plan – active exercise at least 30 min/day

More goals and referrals? No big deal, same as before…

6a-4 Health Concern/Problem 4 = peripheral vascular and neuropathy risks leading to heightened foot complication risks

Goal 4 = improve and maintenance of optimal foot health: aim at early detection of peripheral vascular problems/angiopathy and neuropathy; and prevention of diabetic foot ulcer, gangrene

Intervention: refer to podiatrist for diabetic foot care plan. Patient to be educated on and regularly perform foot self-examination, use proper footwear, regular exercises, attend scheduled follow-up

Nothing new here folk, move right along. But it does raise the question – how much of the goal should be text, and how much should be coded? Coded is nice, but only worth the effort if someone is going to do something with it. FHIR offers extensions as the way to represent this – it’s up to each implementation to decide if the extra effort involved in doing so is worth it…

 6a-5 Health Concern/Problem 5 = non-conformance to medication management regime resulting in potential risks of glycaemic control failure and heightened cardiovascular risks inherent to Type II DM and cardiovascular problems

Goal 5 = improve medication management conformance and patient knowledge on medications

Intervention: refer to community pharmacy for effective medication management plan. Patient to be educated on the risks of non-conformance and benefits of adherence to medication regimes for proper control of blood cholesterol, hypertension, glycaemic level and HbA1c; also education on potential medication side effects, management and reporting

 Same as before.

6a-6 Health Concern/Problem 6 = health literacy deficit which may impact on self-care willingness and ability

Goal 6 = address patient knowledge deficit on diabetic self-care: aim at addressing patient’s knowledge deficit, ensure optimal self-care and prevention/minimization of complications

Intervention: refer to diabetic nurse educator to assess level of knowledge deficit and implement a diabetic patient education plan. Patient to be educated on his conditions – Type 2 DM and the extrinsic (additional) health risks that DM can impact on hypercholesterolemia and hypertension; the importance of glycaemic control, diet control, weight loss, foot care, eye care; prevention and emergency care of hyperglycaemic and hypoglycaemic episodes etc

Same as before.

 

So that’s my first cut at how FHIR can be used to realize this scenario. There’s much more detail required of course, but we haven’t come across any situations where we need a new resource, and one thing is quite apparent – and that is to what extent we want to code data – especially in the careplans and goals. Currently, I doubt that many existing systems will code these goals and that just being able to represent them as text is a major step forward – but if there is a need to code them, then FHIR offers a mechanism to do so.

enjoy!

 

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.

7 Responses to Clinical Scenarios in FHIR

  1. Agree it probably makes sense to leave out the dispense history that shows non-compliance. However, might want to capture the general non-compliance as a Condition – it’s still a “problem” that needs to be tracked.

    What’s the extension for BMI?

    There’ll be a draft RiskAssessment/Prognosis resource that might be useful in representing the specific cardiovascular and neurovascular risks for the patient.

    Disagree there’d be an Order associated with the MedicationPrescription (unless the clinician is routing it to a particular pharmacy for immediate filling)

    My leaning would be to represent all of this as a single CarePlan rather than separate.

    So total resource list for this one is: Patient, Practitioner, Observation(lots), Condition (a few), List, Encounter, RiskAssessment?, CarePlan, MedicationPrescription, Referral?

  2. Rob Hausam says:

    In many cases it may not be as difficult to assess compliance in the ambulatory setting as it would first appear. I recently encountered this again with one of the (few) patients that I’m regularly treating. If you prescribe a medication with enough refills authorized to last for 3 months, but you’re then not asked for additional refills until over 5 months later – that’s a pretty good indicator that there’s a compliance issue that should be addressed!

    It’s also hard for me to imagine that linking Observations to Encounters is not in the 80% for clinical systems. It seems like that functionality, at least at some level, is necessary for all clinical systems. It’s really a pretty key organizing principle in an EHR, so (at least eventually) I can’t see why it wouldn’t be in core. For now, a standard HL7 extension would make sense.

    • David Hay says:

      Hi rob – that’s certainly true, and if you (or your system) has access to dispensing feeds then it becomes possible to automate the process. You could imagine a ‘monitor’ program that raises alerts if it doesn’t receive expected dispense resources within some period. (Given the current discussion on the list, I wonder if that would qualify as an adverseEvent – patient did not get meds). Thanks for your comment…

      • BTW, it was a part of dropped stage 3 requirements – “Medication adherence – Access medication fill information from pharmacy benefit manager
        (PBM) – Vendors need an approach for identifying important signals such as: identify data
        that patient is not taking a drug, patient is taking two kinds of the same drug…”

  3. Pingback: Clinical Scenarios in FHIR – II | Hay on FHIR

  4. Pingback: Clinical Scenarios in FHIR | Hay on FHIR

  5. Pingback: FHIR Clinical scenarios: Nutrition Assessment | Hay on FHIR

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