201901 Public Health

DRAFT Public Health (Case Reporting, Registries, and Referrals)

Submitting WG/Project/Implementer Group

Public Health (PH) Work Group

Justification

Public health includes a number of use cases involving the exchange of information between Electronic Health Records in clinical care and governmental Public Health Agencies (PHAs) or other extra-clinical organizations. The use cases differ, but they frequently have a number of common design elements as well. Because the data exchange is inherently interorganizational, and because initiating events frequently occur in healthcare, unsolicited “push,” messaging, and other reporting components are important use case needs. This Connectathon will focus on common components like FHIR messaging and clinical infrastructure to support reporting to many different extra-clinical organizations, as well as specific transactions for disease surveillance and chronic disease prevention and management. Electronic case reporting (eCR) has existing CDA product family standards and has a FHIR in-process ballot. This use case will focus on the FHIR subscription dissemination of public health “knowledge distribution” including reporting trigger codes in a PlanDefinition construct and also establishing a path for distribution of reporting criteria and more complex business logic. It will also involve the triggering and creation of the electronic Initial Case Report (eICR) in EHRs, the messaging and exchange of the eICR, and the creation and transmission of Reportability Response information back to providers of care and clinical care reporters as appropriate. The FHIR electronic Case Reporting implementation guide currently in ballot can be found here:

• http://hl7.org/fhir/us/ecr/2018Sep/index.html.

Public health registry reporting shares numerous design elements with electronic case reporting. Some of these elements include the distribution of triggering / reporting rules from public health, appropriate triggering in EHRs, the application of more complex inclusion/exclusion and reporting logic, unsolicited push messaging, supplemental data acquisition, and provider information provisioning. Cancer reporting and others are exploring approaches to implementation that support needed program outcomes from clinical workflow and data and leverage commonalities with other reporting. The CDC Cancer program plans to work on a FHIR physician reporting specification and triggering issues in this Connectathon.

Bidirectional Services eReferrals (BSeRs) are closed-loop exchanges between EHRs in clinical care and mostly extra-clinical social services and lifestyle change programs. There is a FHIR BSeR September ballot with transactions to support the transmission of a referral and response and update communications from the program back to the referring provider. Numerous Centers for Disease Control and Prevention and other agency programs seek to facilitate cessation and prevention programs to increase health and decrease healthcare costs. Unlike referrals between clinicians, specific data segmentation is appropriate to provide these programs relevant data they need without revealing unrelated patient information. The FHIR Bidirectional Services eReferral specification can be found here:

• http://hl7.org/fhir/us/bser/2018Sep/.

Proposed Track Lead

• Rick Geimer
• John Loonsk
• Arun Srinivasan

See Connectathon_Track_Lead_Responsibilities

Expected participants

• Association of Public Health Laboratories
• Centers for Disease Control and Prevention
• Cerner Corporation
• CGI Federal
• Lantana Consulting Group
• Northrup Grumman
• Alliance of Chicago
• YMCAs of America

Roles

Public Health

Responsible for managing and disseminating trigger codes, decision logic, and knowledge resources. It fosters disease control and prevention programs and activities.

Public Health Agencies

Agencies that receive and manage electronic Initial Case Reports (eICRs), and at times send and/or receive Reportability Responses. Some Public Health Agencies support lifestyle and social services programs.

Intermediaries

Organizations in the information flow between a health care organization and a public health agency or extra-clinical program. Examples include Health Information Exchanges, the shared platform supported by APHL and CSTE that performs routing, RCKMS decision support and, at times, creates Reportability Responses, etc.

Health Care Organization

An organization that submits electronic Initial Case Reports (eICRs) based on trigger code matches, and receives trigger code updates and Reportability Responses. Health Care Organizations also report to public health registries and initiate referrals to extra-clinical social services programs. The health care organization can be supported by an EHR vendor in these roles.

Social Services and Lifestyle Change Programs

Organizations that provide classes, planning, counseling, and/or expertise in the control and prevention of chronic and acute diseases, tobacco cessation, diabetes prevention and others.

EHR Document / Report Creator

Organization responsible for creating an electronic initial case report (eICR) or another report and sending it to a EHR Document Report Receiver. Examples: EHR vendors and specialty reporting companies.

EHR Document / Report Receiver

Organization responsible for receiving and processing an electronic initial case report (eICR) and registry submissions. Examples: APHL, public health registry, or a public health agency (PHA). The eICR Document Participant may also play the role of a Reportability Response Document Creator.

Reportability Response Creator

Organization responsible for creating a Reportability Response (RR) and sending it to a Reportability Response Document Consumer. Examples: APHL or a public health agency (PHA). The Reportability Response Document Creator may also play the role of an eICR Document Participant.

Reportability Response Consumer

Organization responsible for receiving and processing a Reportability Response (RR). Examples: EHR vendors and specialty reporting companies). The Reportability Response Document Consumer may also play the role of an eICR Document Creator.

Scenarios (Reporting)

The Reporting scenarios will use the AIMS Platform's experimental FHIR Server. To access it:

• Go to https://fhir.experimental.aimsplatform.com
• Select "API Key" in top-right
• Click "Login"
• Register/login. It will re-direct you back to the HAPI/FHIR server when done. Required fields are first, last, email, username, and password.
• Select "API Key" in the top-right, again
• It will show you your token, so that you can use it in FHIR REST API requests

For example: GET https://fhir.experimental.aimsplatform.com/baseDstu3/Bundle/1 with an "Authorization" header of "Bearer <your_token>" The token stays active for 24 hours, and then it expires, and you have to re-login to get a new token

For those who wish to try FHIR messaging for any of the scenarios, there is a sample message header here: http://hapi.fhir.org/baseDstu3/MessageHeader/1156783.

The Zulip thread for the Public Health track is here: https://chat.fhir.org/#narrow/stream/179207-connectathon-mgmt/topic/Public.20Health.20Track

Update Knowledge Distribution / Trigger Codes on Public Health FHIR Server

In this scenario and elsewhere we refer to “trigger codes / reporting logic” which is used to refer to distributable knowledge resources that will be used by clinical care / EHRs to support triggering and reporting. Coordinated through a PlanDefinition, they include value set bundles and other reporting metadata and eventually CQL and other knowledge resources. For some time, the value set bundles may be the only machine processable XML and JSON content, but the additional information provides human processable context and a standards-based wrapper to coordinate these elements.

Action: Public Health determines that the current trigger code value sets / reporting logic require an update. The appropriate value sets are updated using PUT. Also update trigger codes as a Bundle of ValueSet resources referenced by the PlanDefinition so they can be updated as a set and linked to other reporting criteria.

Precondition: Original trigger code value sets / reporting logic exists on test server

Success Criteria: Value sets are successfully updated and can be retrieved on demand with GET

Subscribe to Knowledge Distribution / Trigger Codes Updates

Action: Provider organization uses Subscription to subscribe to changes to the PlanDefinition and trigger code value sets / reporting logic using any legal notification method.

Precondition: Original PlanDefinition and trigger code value sets / reporting logic exist on test server

Success Criteria: Provider organization is notified and receives a copy of any PlanDefinition and trigger code value sets / reporting logic specifications that are updated

Ingest Knowledge Distribution / Trigger Codes into EHR

Action: Provider organization receives a PlanDefinition trigger code / reporting logic update, and ingests them into their EHR to support case report initiation.

Precondition: PlanDefinition trigger codes / reporting logic updates have been received by provider organization

Success Criteria: Updates successfully ingested into EHR

Create and Send eICR Document

Action: Document Creator prepares an eICR (or other registry submission) and POSTs it to a FHIR server. This POST may be one of several different transport methodologies supported for exchange with public health and other extra-clinical organizations. Some may test FHIR messaging for transmissions.

Precondition: Patient and Encounter resources exist, and sufficient clinical information (Condition, Observation, and other resources) to populate an eICR.

Success Criteria: eICR is successfully posted to a FHIR server and validates against the eCR profiles found here:

• http://hl7.org/fhir/us/ecr/2018Sep/profiles.html#electronic-initial-case-report-eicr-transaction-and-profiles

Receive eICR Document

Action: eICR Document Creator prepares an initial case report and POSTs it to a FHIR server. This POST may be one of several different transport methodologies supported for exchange with public health. eICRs will be queued. The eICR Document Consumer does a GET on each successive eICR and processes it. Some may test FHIR messaging for transmissions.

Precondition: eICR exists on a FHIR server.

Success Criteria: eICR is successfully retrieved from a FHIR server and validates against the eCR profiles found here:

• http://hl7.org/fhir/us/ecr/2018Sep/profiles.html#electronic-initial-case-report-eicr-transaction-and-profiles

Create Reportability Response (RR)

Action: RR Document Creator prepares a reportability response and POSTs it to a FHIR server. This POST may be one of several different transport methodologies supported for exchange with clinical care. Some may test FHIR messaging for transmissions.

Precondition: eICR on which the RR is based exists and contains sufficient information to create an RR.

Success Criteria: RR is successfully posted to a FHIR server and validates against the eCR profiles found here:

• http://hl7.org/fhir/us/ecr/2018Sep/profiles.html#reportability-response-rr-transaction-and-profiles

Receive Reportability Response

Action: RR Document Creator prepares reportability response and POSTs it to a FHIR server. This POST may be one of several different transport methodologies supported for exchange with clinical care. RRs will be queued. The RR Document Consumer does a GET on each successive RR and processes it. Some may test FHIR messaging for transmissions.

Precondition: RR exists on a FHIR server.

Success Criteria: RR is successfully retrieved from a FHIR server and validates against the eCR profiles found here:

• http://hl7.org/fhir/us/ecr/2018Sep/profiles.html#reportability-response-rr-transaction-and-profiles

Scenarios (Referrals)

Create and Send Referral

Action: EHR prepares and POSTs an electronic referral. This POST may be one of several different transport methodologies supported for exchange with clinical care. The referral receiver does a GET on each successive referral and processes it. Some may test FHIR messaging for transmissions.

Precondition: Referral exists on a FHIR server.

Success Criteria: Referral is successfully retrieved from a FHIR server and validates against the profiles found here:

• http://hl7.org/fhir/us/bser/2018Sep/ReferralRequestTransactionProfiles.html

Receive Referral

Action: Referral creator prepares referral and POSTs it to a FHIR server. This POST may be one of several different transport methodologies supported for exchange with clinical care. Referrals may be queued. The referral consumer does a GET on each successive referral and processes it. Some may test FHIR messaging for transmissions.

Precondition: Referral exists on a FHIR server.

Success Criteria: Referral is successfully retrieved from a FHIR server and validates against the profiles found here:

• http://hl7.org/fhir/us/bser/2018Sep/ReferralRequestTransactionProfiles.html

Create and Send Report Back

Action: A referral report is created and POSTed it to a FHIR server. This POST may be one of several different transport methodologies supported for exchange. Some may test FHIR messaging for transmissions.

Precondition: Referral report information exists sufficient to populate a referral report.

Success Criteria: Referral report is successfully posted to a FHIR server and validates against the profiles found here:

• http://hl7.org/fhir/us/bser/2018Sep/ReferralFeedbackTransactionProfiles.html

Receive Report and Attach to Patient Chart

Action: Referral report creator prepares a referral report and POSTs it to a FHIR server. This POST may be one of several different transport methodologies supported for exchange with clinical care. The referral consumer does a GET on each referral report and processes it. Some may test FHIR messaging for transmissions.

Precondition: Referral report exists on a FHIR server.

Success Criteria: Referral report is successfully retrieved from a FHIR server and validates against the profiles found here:

• http://hl7.org/fhir/us/bser/2018Sep/ReferralFeedbackTransactionProfiles.html

Scenarios (Cancer)

Create a Cancer Registry Profile and Extensions (Cancer Specific)

In this scenario, the reporting to the Cancer Registry requires inclusion of Treatment Plans, Planned Medication Activity, Radiation treatment and results, Family History, Vital Signs, and Cancer Diagnosis elements. This activity involves assessing gaps between existing FHIR resources and necessary Cancer Reporting elements, in order to define a FHIR Profile and Extensions that meets the requirements of Cancer Reporting.

Action: Public Health creates a Cancer Registry Profile and Extensions that captures information needed to support a FHIR Document for Cancer Registry report.

Precondition: Patient, Encounter, and Diagnostic Reporting resources exist on EHR FHIR Server, and sufficient clinical information (Patient, Encounter, Diagnostic Report, :Condition, Observation, and other resources) to populate an Ambulatory Cancer report is available on EHR FHIR Server.

Success Criteria: FHIR Profile and Extensions for Cancer Reporting are created and include elements to support cancer reporting

Update Trigger Codes / Reporting Logic on Public Health FHIR Server (Cancer)

In this scenario and elsewhere we refer to “cancer trigger codes” which is used to refer to distributable knowledge resources that will be used by clinical care / EHRs to support triggering and initiating a FHIR Document to support reporting to Cancer Registries.

Action: Public Health determines that the current “cancer trigger codes / reporting logic” trigger code value sets / reporting logic require an update. The appropriate value sets are updated in the Public health FHIR Server. Also, a Bundle of Cancer Value Set resources, referenced by the PlanDefinition, will be updated.

Precondition: Original trigger code value sets / reporting logic exists on Public Health FHIR server.

Success Criteria: Value sets are successfully updated and can be retrieved on demand with GET.

Subscribe to Cancer Trigger Code Updates

Action: Provider organization uses Subscription to subscribe to changes to the PlanDefinition and trigger code value sets using any legal notification method. :Precondition: Original PlanDefinition and trigger code value sets exist on test server Success Criteria: Provider organization is notified and receives a copy of any PlanDefinition and trigger code value sets / reporting logic specifications that are updated. Provider ingests Cancer Trigger Codes into EHR Action: Provider organization receives a PlanDefinition Cancer trigger code update, and ingests them into their EHR to support Cancer Registry report initiation.

Precondition: PlanDefinition Cancer trigger codes updates have been received by provider organization

Success Criteria: Updates successfully ingested into EHR

Create and Send Cancer FHIR Registry Report Document (Cancer Specific)

Action: EHR prepares a FHIR Document based on the FHIR Profile for Cancer Reporting and Posts it to the Public Health FHIR Server. This POST may be one of several different transport methodologies supported for exchange with clinical care. Some may test FHIR messaging for transmissions.

Precondition: Cancer Report trigger has fired, and FHIR Profile for Cancer Reporting exists on a FHIR server.

Success Criteria: FHIR Document for Cancer Report is posted and can be retrieved from Public Health FHIR server and validates against the cancer profiles found here: (Zulip Public Health track)