Follow-up questions from FHIR & Ice

At our recent ‘FHIR & Ice‘ seminar, we tried to answer as many question as we could, but we did ask people who attended if there were outstanding ones that we could have covered. Here is our attempt to answer them, I did the FHIR ones and my colleague Alastair Kenworthy the SNOMED ones.

What can clinicians do to implement FHIR?

In a word get involved! As we’re said a number of times, FHIR has been designed for implementers – and this includes clinicians and analysts as well as technical folk. The underlying structure of FHIR is quite straightforward (at least at the level that clinicians need to understand) so use the clinFHIR tool to help ‘browse’ the resources – it has links to the spec as well. The profiling mechanism allows you to express what you’re trying to communicate, and we’re continuing to evolve the tooling to support that. We’re also happy to host more events – especially aimed at Clinicians – if there is interest.

What about testing of FHIR – are there any tests?

Do you mean the actual spec? Sure. The whole thing is constructed from a few core inputs (we use excel spreadsheets as a UI for the main part and text in XML files), but the whole spec is generated by an application, and that ‘build process’ includes extensive verification so the spec quality is extremely high – including validating all examples.

Use of style sheets for displaying the text elements of resources and indeed an entire resource

There isn’t an ‘official’ XSLT file as there was for CDA, but it’s straightforward to build with resources in XML format. The text element is a subset of XHTML.

As I know semantic web (SW) technology is one of the powerful approach to enable machines to understand meaning and relationships between contents and information – I am curious about the difference among SW and FHIR.

I’m not sure I’m best placed to answer that question! I’ll post it here in the hope that someone more expert than I can contribute. I’ll also send it to the FHIR List (an email to and update with any feedback I get

Data validation and security

There is tooling to validate resources against profiles (and even the core resources have a profile behind them). I’ve not used it as yet – I’ll make a mental note to investigate and post about it! Security we defer to the existing standards that have been developed (SSL, OAuth2, Certificates etc) with ‘hooks’ where needed. More on security here.

Using FHIR in national systems like NES,NIR (National Immunization Registry),EPS (Electronic Prescription Service) etc

Well, they are certainly candidates for a FHIR interface, and will be a lot easier than the current mechanisms (once the required infrastructure is in place) so that will make it easier for vendors to participate. New Zealand has announced support for FHIR officially (here is the announcement) which is an important step, but I do believe that there needs to be a more concerted national focus – and funding for projects – to move this forward. Start agitating for it!

What tools are available for testing SNOMED CT concepts?

IHTSDO, the SNOMED CT parent body, develops a number of open source tools for building and managing SNOMED CT content, including the SNOMED CT member licensing and distribution service, SNOMED CT browser and SNOMED CT reference set manager. The source code is posted on Github.

With respect to the SNOMED CT implementation strategy and timetable from the Ministry of Health, has funding been allocated?

The Ministry of Health licenses SNOMED CT for the sector’s free use by paying an annual membership fee to the IHTSDO and having representatives on IHTSDO committees. The Ministry operates the SNOMED CT national release centre, distributing SNOMED CT in New Zealand and promoting its use as part of e-health initiatives. A number of implementations are underway in medicines, emergency care, e-referral and outpatients. Some of these projects receive central funding. A definite timetable and incentive programme for widespread SNOMED CT adoption can be expected as part of the next five year national e-health plan.

How do we bring SNOMED CT into general usage without impacting the efficiency of health care delivery?

One of the expected benefits of SNOMED CT as a tool for much better information is more efficient health care delivery. In the short term, however, SNOMED CT is a new technology whose introduction will have to be carefully managed. This will require fresh thinking about how applications work and, in particular, how clinical concepts can be accurately and smoothly selected at the user interface.

What are the guidelines for deploying SNOMED CT into electronic medical record systems?

SNOMED CT will completely replace the outdated Read codes in electronic medical record systems in primary and secondary care. For simple purposes, this could be more or less a straight swap of one system for the other. But SNOMED CT will inevitably be used much more extensively than Read codes ever were, and applications will need to adapt to the fast paced demands of busy and increasingly mobile clinicians.

How can SNOMED CT be used for reporting?

SNOMED CT is a vast network of clinical concepts, with many kinds of interconnection between terms. Some relationships are hierarchical and these can be used to roll up clinical information for reporting. There are also published maps from SNOMED CT to ICD-10-AM for statistical reporting and activity based costing.

Could SNOMED fully describe a personal care plan across a multi-disciplinary team?

SNOMED CT concepts exist for medical conditions, situations, objectives and interventions and other actions. Coupled with ‘who’ and ‘when’ information, these concepts provide the building blocks of shared care plans. A successful interface terminology is the Omaha System for community nursing, which is tied to SNOMED CT as the underlying reference terminology.

About David Hay
I'm an independent contractor working with a number of Organizations in the health IT space. I'm an HL7 Fellow, Chair Emeritus of HL7 New Zealand and a co-chair of the FHIR Management Group. I have a keen interest in health IT, especially health interoperability with HL7 and the FHIR standard. I'm the author of a FHIR training and design tool - clinFHIR - which is sponsored by InterSystems Ltd.

4 Responses to Follow-up questions from FHIR & Ice

  1. Actually, RDF and the Yosemite Project provide one crossover point between Semantic Web and FHIR. It’s well worth reviewing. Josh Mandel talks about it here:

  2. Pardhasaradhi says:

    HI David,
    This is pardha working as Sr.Software Developer. I’m trying to validate a Basic Resouce on FHIR using c#.As per FHIR( we are using this resouce for customize segements(like ZDS segment in HL7V2).

    My questions are listed as below:

    1.What are the mandatory the elements(POST,GET,PUT operations) in Basic Resouce?
    2.Need use case for this resource?(Workflow)

    If you Provide video tutorial for this use case and Healthcare domain knowledge along with realtime scnarios it could be easily understood our team as well.

    Thank You,

    • David Hay says:

      Hi Parda,

      From the perspective of operations – or API calls against a FHIR server, there’s nothing mandatory in the spec. A server implements what it needs to, and then declares what it can do in the conformance resource (that a client can access using the uri [fhir root]/metadata). This is the same for all resources.

      From the perspective of a resource, some of the elements are required – though we try to keep those to a minimum. Profiling allows a designer to alter that (making optional elements required, though not the other way round) – for example they could say that is required for their use case – as well as adding extra fields using extensions. For example, you may wish to record a patients caste (if that is appropriate, apologies if not) – that could be represented as an extension on Patient

      The Basic resource exists when none of the other resources suit a particular use case, and allows you to remain in the ‘FHIR family’ while continuing to meet your requirements. So it pays to make sure that there is no better match in any of the other resources.

      Finally, can I suggest that you look at – this is a site that we’ve just established for people to be able to interact with the community. You’d be very welcome, and would have the ability to ask your questions of the experts in the field. (Of course you’re very welcoome to ask here as well – but there are a lot of people in the chat!


  3. Pingback: HL7 New Zealand Mid-year Seminar: Fire and Ice – HL7 New Zealand

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