FHIR Questionnaires and Structured Data Capture...•Brian Postlethwaite •Senior Solutions Architect - Telstra Health •HL7 International Patient Administration co-chair •HL7

HL7 FHIR DevDays 2020, Virtual Edition, November 17–20, 2020 | @FirelyTeam | #fhirdevdays | www.devdays.com/november-2020

HL7®, FHIR® and the flame Design mark are the registered trademarks of Health Level Seven International and are used with permission.

FHIR Questionnaires and Structured Data Capture

Brian Postlethwaite

1

Who am I?

• Brian Postlethwaite

• Senior Solutions Architect - Telstra Health

• HL7 International Patient Administration co-chair

• HL7 FHIR Management Group member

• .NET fhir-net-api and fhir-net-web-api contributor

• Implementer of SDC!

• Working with FHIR since 2014!

2

What is going to be covered?

• Uses

• FHIR Resource Definitions

• Workflows

• Validation & Handling Errors

• Creating Questionnaires

• Tools/Projects

• Rendering

• Pre-population

~ Survey Monkey for FHIR

Why did we standardize it?

3

Structured Data Capture (SDC) Implementation Guide

•Extensions to the core HL7 definitions• Advanced Rendering• Advanced Form Behaviour• Importing Data into Forms• Extraction of Data from Forms

•Close to publication

http://build.fhir.org/ig/HL7/sdc/

4

Uses of FHIR Questionnaires

• Assessments (Primary Care)

• Assessments (consumer)

• Surveys

• Gov't/Statutory forms

• Referrals template

• Admission form

• Care Plans

• Research

• Oncology

• Pathology

• Public Health Reporting

• Insurance/Payments

• General data entry

5

FHIR Questionnaire Artifacts

• Questionnaire Resource• Definitional Resource

• Similar to StructureDefinition

• May include ValueSet / Terminologies

• QuestionnaireResponse Resource• Record of responses

• Structure mirrors Questionnaire items

• Other• Extensions, Operations, Profiles, Implementation Guides (incl SDC)

6

Resource Definitions

Questionnaire

• Metadata

• Items (nested)• LinkId

• Text

• Item Type

• repeats

• Data rules (validation)

• Formatting hints

QuestionnaireResponse

• Context

• Items (nested)• LinkId (must match)

• Answer value

LinkId joins answer to definitionMUST MATCH

(including the nesting depth)

Item-Type Response Type Definition

group item(Group) An item with children, may be repeating. Could be a section, table or other layout (e.g. tabs)

display (none) Just a label to be displayed (no answer to be collected)

boolean valueBoolean Yes/no answer (checkbox, radio group or similar)

decimal valueDecimal Real number answer (restricted textbox, slider, …)

integer valueInteger Integer answer (restricted textbox, slider, …)

date valueDate Date answer (restricted textbox, date picker …)

dateTime valueDateTime Date and time answer (restricted textbox, date picker …)

time valueTime Time only answer (hour:minute:second) answer independent of date (restricted textbox, …)

string valueString Short free-text answer (single line textbox)

text valueString Longer free-text answer, potentially multi-paragraph (multi-line textbox)

url valueUri URL (website, FTP site, etc.) answer (restricted textbox)

choice valueCoding Coding drawn from a list of options (specified in either the option property, or via the ValueSet referenced in the options property) as an answer (radio buttons, checkboxes, combobox, autocomplete …)

open-choice valueCoding or valueString

Coding drawn from a list of options (as with the choice type) or a free-text entry in a string (similar controls to choice, except with ability to include textbox)

attachment valueAttachment Binary content such as a image, PDF, etc. as an answer (file selector …)

reference valueReference A reference to another resource, e.g. practitioner, organization, etc. (resource finder?)

quantity valueQuantity Question with a combination of a numeric value and unit. ()

http://hl7.org/fhir/valueset-item-type.html

8

Interaction with terminologies

Questionnaire structure• Item types

• Choice, open-choice

• Valueset reference (canonical!)• Item.answerValueSet

• Answer options• valueCoding, initialSelected

• Repeat

• Control selection• Radio buttons, comboboxes, checkboxes,

autocomplete

• Consider the number of potential entries in the list

Extensions• questionnaire-itemControl

• questionnaire-optionExclusive

• preferredTerminologyServer

• questionnaire-unitValueSet

• 11179-permitted-value-valueset

• 11179-permitted-value-conceptmap

Operations

Use the ValueSet $expand operation to either pre-load the values, or use the filter parameter for the auto-complete style usage

9

Initial Value

• Defaulted when creating initial QuestionnaireResponse

• Repeating groups• When a new repetition of a group is

added, initial values should be included

• When using answerOption, then it’s InitialSelected flag indicates which option is used

• May be done client, or server (during $populate)

• SDC: Initial Expression (FHIRpath)

10

Dynamic Behaviour - Enable when

• SDC: EnableWhen Expression (FHIRpath)

• Effects Validation and required

11

Sample Questionnaires

• Enable When radio buttons

• Chained enable when

• Enable When tests

• Bit of Everything – all item types

• Fitness study

• HACC MDS Survey

https://sqlonfhir-r4.azurewebsites.net/fhir/Questionnaire

12

Workflow

• Locate questionnaire to use (for given context)

• Load/render questionnaire (and referenced content)• Pre-populate questionnaire with other data (e.g., patient

demographics, observations etc)

• User enters data• Local validations may occur during data entry

• QuestionnaireResponse is validated by server• Errors/Warnings/issues reported to the user

• QuestionnaireResponse is saved to the target server• Data extracted into other resources

13

Fetching Questionnaires

• Standard FHIR Search API• e.g., by id, title, publisher,

context, etc.• Through references in a

directory

14

Rendering Questionnaires and Recording Responses in QuestionnaireResponse

• User interface to interpret definition, and create response data

• Definition guides user entry, may be different based on data entry device• Mobile, web, native application

• May be validated on client and server

• SDC Provides Advanced Rendering Guidance and Definitions

• LinkId joins answer in QuestionaireReponse to definitions in Questionnaire• MUST MATCH (including the nesting depth)

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Posting Answers and Subsequently Fetching

• POST to FHIR server• Validates content (draft status may

permit invalid saves)

• May perform additional processing

• Standard FHIR Search API• QuestionnaireResponse.id

• Questionnaire Canonical

• patient demographics (through chaining)

• Status

• Note that individual responses are not directly searchable using the FHIR RESTful API.

• Requires additional processing to other resource types$extract

16

Validation and Handling Errors• FHIR json/xml valid (serialization)

• Core FHIR profile validation (maybe local profiles too)

• QuestionnaireResponse validation• Item Types/Datatypes (using linkId to match)

• Terminology

• Required Fields

• Enable When should be considered

• Repeating fields are per group repetition

• answerOptions/Extensions/Complex Validation

• Base Questionnaires through derivedFrom reference

• Custom validation?

• OperationOutcome• Content/messages appropriate to display to users?

• Location of issue – which control (via linkId)

Validation display example - SmartQedit R4 (smartqedit4.azurewebsites.net)

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Complex Validation

• Cross field validation

• Conditional rules

• Complex calculations

• Custom Error messages

• Core resources can be profiled with invariants

• Extension adds this capability to Questionnaires

https://sqlonfhir-r4.azurewebsites.net/fhir/Questionnaire/sa-rtw-r4

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Complex Validation – FhirPath Expression

http://hl7.org/fhir/extension-questionnaire-constraint.html

19

Creating Questionnaires

• Converting existing non FHIR definitions

• U.S National Library of Medicine's Form Builder for LHC-Forms/FHIR Questionnaire (STU3, R4)

• Grahame Grieve’s editor (FHIR Toolkit)

• Telstra Health SmartQ editor (broken)

http://smartqedit4.azurewebsites.net

• Beda Software editorhttp://ui.hl7.beda.software/

• https://fhirpower.bitrix24.site/Stoyan Halaliev (new)

• Using text editor

• Others?

(or combination of the above)

https://lhncbc.github.io/lforms-fhir-app/US National Library of Medicine (USA)

http://ui.hl7.beda.software/questionnaire/edit/dc66fb8f-60b9-4aea-bc4f-4d0e976320aaBeda Software

https://fhirpower.bitrix24.site/ Stoyan Halaliev (Germany)

https://github.com/brianpos/fhirpathtesterBrian Postlethwaite

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Open-Source Projects

• https://github.com/lhncbc/formbuilder-lhcforms

• https://github.com/beda-software/sdc-hl7-sydney

• https://github.com/beda-software/aidbox-sdc

• https://github.com/FHIR/fhir.js

• https://github.com/gavinl/fhirq-renderer

• https://github.com/brianpos/fhirpathtester

• https://www.microsoft.com/store/productId/9NXV8QDQ154V

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Pre-population

• Requires:• context/source

• mapping

• processing engine

• Knowledge of source structures(particularly profiled scope)

• Current $populate Options:• Observation based

• FHIRPath based

• StructureMap based

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Pre-population – Observation based

• Low flexibility of Questionnaire structure in mapping

• Source• Context may be provided in parameter, or SMART

• Item.code for LOINC/SNOMED/other to search

• Extension questionnaire-observationLinkPeriod to define range to check for last observation to read

• Mapping• Item.code for LOINC/SNOMED/other for the values to be

extracted from the observation

• Groups can be used for extracting observation components

• If the system understands that codings like LOINC 21112-8 is patient.birthDate, then it may extract data like this also

28

Pre-population – FHIRPath based

• Source• Context may be provided in parameter, or SMART

• Extension questionnaire-launchContext

• Produces a bundle for processing

• Mapping• FHIR Path expressions for each property to map

• Extension “questionnaire-itemPopulationContext”

• Extension “sdc-questionnaire-initialExpression”

• Leverage variables to assist in calculations• Extension “variable” uses Expression datatype

More Flexible, requires knowledge of FHIRPath and FHIR Queries to create the mappings

29

Demo Pre-Population

https://smartqedit4.azurewebsites.net/Questionnaire/Populatehttps://smartqedit4.azurewebsites.net/Questionnaire/pmstest

http://sqlonfhir-r4.azurewebsites.net/fhir/Library

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What did you learn?

• Questionnaire / QuestionnaireResponse• Basics

• Data Types

• Terminology Interactions

• Advanced Validation

• Form prefill from other FHIR resources ($populate)

• Open Source / Existing tooling

32

Contact

• During DevDays, you can find / reach me here:• Via Whova App – Speaker’s Gallery

• Email: [email protected]

• FHIR Chat: Zulip

• Other Relevant Sessions:• Customizable Universal Forms

• Ilya Beda

• Thursday 19th Nov 8:00am – 8:45am (check your schedule)

• In this session he is going to demonstrate at least $populate, $expand and $assemble operations.

33

Q&A

• Questionnaire / QuestionnaireResponse• Basics

• Data Types

• Terminology Interactions

• Structure Data Capture• Form prefill from other FHIR resources

• Advanced Validation

• Converting QuestionnaireResponse data into other resources

• Open Source / Existing tooling