Building Interoperability with FHIR systems

Exchange patients and reports with FHIR compliant systems

Overview

CHT has an interoperability tool which supports building FHIR workflows. You can see more details of the tool in the cht-interoperability repository. The following FHIR resources are supported:

Sending Patient data from the CHT to interoperating systems.
Sending reports as Encounters with Observations from the CHT to interoperating systems.
Sending Patient data created in interoperating systems to CHT applications.
Sending health information represented as Encounters with Observations from interoperating systems to CHT applications.

Sending Data

When sending data to an interoperating system, outbound push is used to configure which documents should be sent and at what point. A mediator then converts these documents to FHIR resources and orchestrates sending them to interoperating systems. The default mediator makes any resources sent to it queryable via a FHIR API using HAPI.

Receiving data

When receiving data from an interoperating system in a CHT application, forms and transitions are configured to map the incoming data to CHT documents. A mediator is responsible for getting these resources from an interoperating system (either by exposing API endpoints or pulling them from an API), and converting from FHIR resources to a format that can be submitted to the records API.

Outbound Patients

When sending Patient data collected from CHT to an interoperating system, first identify which documents represent patients. In the example below, a patient is a document with type person and role patient. This may not apply to all CHT applications. Then, create an outbound push configuration to send these documents to the interoperating system.

The outbound push config contains the following fields.

Field	Description
`relevant_to`	An “expression” (some JS code that resolves to a truthy or falsy value) that defines which documents are patients.
`base_url`	The url of the OpenHIM instance where the mediator is hosted
`path`	`/mediator/cht/patient`

Add a condition in the relevant_to field; whenever any documents matching this condition are created or updated, a request will be sent to the url specified in base_url and path.

The fields in the patient document need to be mapped to the FHIR format. It is possible to convert the document to a FHIR Patient resource in outbound push config (an example can be found in the reference application). This can be difficult to configure correctly, so the default mediator also accepts a shorter form which is the id, name, phone, date_of_birth and patient_id fields from the document itself.

The mapping field in outbound push config contains the following fields.

Field	Description
`_id`	CouchDB’s unique identifier of the record. This will be converted to an Identifier with type `CHT Document Id`.
`name`	Patient’s name.
`phone`	Patient’s phone number.
`date_of_birth`	Patient’s date of birth.
`sex`	Patient’s sex.
`patient_id`	If a separate `patient_id` is generated, it can be sent here. This will be converted to an Identifier with type `CHT Patient Id`.

This example outbound push config selects documents where patient_id exists, and doc.role === patient:

{
  "patient": {
    "relevant_to": "doc.type === 'person' && doc.patient_id && doc.role === 'patient'",
    "destination": {
      "base_url": "http://openhim-core:5001",
      "path": "/mediator/cht/patient",
      "auth": {
        "type": "basic",
        "username": "interop-client",
        "password_key": "openhim1"
      }
    },
    "mapping": {
      "doc._id": "doc._id",
      "doc.name": "doc.name",
      "doc.phone": "doc.phone",
      "doc.date_of_birth": "doc.date_of_birth",
      "doc.sex": "doc.sex",
      "doc.patient_id": "doc.patient_id"
    }
  }
}

Outbound Reports

To send reports from the CHT to an interoperating system, an Encounter resource is created to represent the encounter between the patient and the CHW. Any data in the report that is sent to the interoperating system is represented as Observations linked to the Encounter.

Encounters have a reference to Patients, so setting up outbound patients is a requirement for outbound reports.

Similarly to patients, create an outbound push configuration with the relevant_to field having doc.type === 'data_record' && doc.form === '{{the form to be sent}}'.

The outbound push config contains the following fields.

Field	Description
`relevant_to`	An “expression” (some JS code that resolves to a truthy or falsy value) that defines which forms should be sent. `doc.type === 'data_record' && doc.form === '{{the form to be sent}}'`.
`base_url`	The url of the OpenHIM instance where the mediator is hosted.
`path`	`/mediator/cht/encounter`

The fields in the form that need to be exchanged need to be mapped to a format that a mediator can convert to Observations. Observations need to have a Code that is understood by the interoperating system, and the response values may need to be converted to a different format.

For example a yes/no question may need to be converted to the presence (if yes) or absence (if no) of an observation with a code.

“Does the patient show signs of fever?” can be converted to an observation with the code for fever if the answer was yes, or be omitted entirely if the answer was no.

Another example is multiple choice questions, which can be converted to a coded question where each of the choices is assigned a code.

“Which danger signs does the patient show?” can be converted to Observations with the code for pregnancy danger signs, and for each danger sign selected, the value is the code of the danger sign.

The mapping field in outbound push config contains the following fields.

Field	Description
`id`	CouchDB’s unique identifier of the record. This will be converted to an Identifier with type `CHT Document Id`.
`patient_uuid`	Document uuid of the patient document that is the subject of the report.
`reported_date`	Date when the report was made.
`observations`	A list of the form fields to be converted to Observations, with format `observations.{{number}}.code` and `observations.{{number}}.{{value}}` where value can be one of `valueCode`, `valueDateTime` and `valueString`.
`observation.n.code`	For each form field to convert to observations, a code for the observation.
`observation.n.valueCode`	For multiple choice questions with valueCoded responses, the code for the response value. If `false`, the observation will be omitted.
`observation.n.valueDateTime`	For datetime questions, the date for the value.
`observation.n.valueString`	For string questions, the value.

In this example, a danger signs question is converted into Observations where danger signs has code 17a57368-5f59-42c8-aaab-f2774d21501e, and the yes/no questions fever and breathlessness with codes 43221561-0600-410e-8932-945665533510 and 070dca86-c275-4369-b405-868904d78156 are present if the response was yes or absent if the response was no.

{
  "relevant_to": "doc.type === 'data_record' && doc.form === 'pregnancy'",
  "destination": {
    "base_url": "http://openhim-core:5001",
    "path": "/mediator/cht/encounter",
    "auth": {
      "type": "basic",
      "username": "interop-client",
      "password_key": "openhim1"
    }
  },
  "mapping": {
    "id": "doc._id",
    "patient_uuid": "doc.fields.inputs.contact._id",
    "reported_date": "doc.reported_date",
    "observations.0.code": {
      "expr": "\"17a57368-5f59-42c8-aaab-f2774d21501e\""
    },
    "observations.0.valueCode": {
      "expr": "doc.fields.danger_signs.fever == \"yes\" ? \"43221561-0600-410e-8932-945665533510\" : false"
    },
    "observations.1.code": {
      "expr": "\"17a57368-5f59-42c8-aaab-f2774d21501e\""
    },
    "observations.1.valueCode": {
      "expr": "doc.fields.danger_signs.breathlessness == \"yes\" ? \"070dca86-c275-4369-b405-868904d78156\" : false"
    },
    "observations.2.code": {
      "expr": "\"1427AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA\""
    },
    "observations.2.valueDateTime": "doc.fields.lmp_date",
    "observations.3.code": {
      "expr": "\"5596AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA\""
    },
    "observations.3.valueDateTime": "doc.fields.expected_date",
    "observations.4.code": {
      "expr": "\"13179cce-a424-43d7-9ad1-dce7861946e8\""
    },
    "observations.4.valueString": "doc.fields.danger_signs.other_any"
  }
}

Inbound Patients

It is also possbile to create patients in the CHT from patients that were created in external systems. Patients in CHT applications are represented as contacts, and require a parent to be assigned to a CHW, facility, or other location. This requires a mediator to have the ids of contacts in CHT and currently cannot be done automatically by the default mediator. A custom mediator needs to be created which assigns a field to use as the parent_id.

To create data in CHT, a mediator converts a FHIR Patient to a json object that it submits as a request to the records API. This requires a form to be configured in the CHT; the incoming data will be saved as a report. Then, the actual patient document is created by assigning a create patient transition to the form.

Because the patient creation form is a CHT form like any other, messages, validations and other transitions can be assigned to it to build more complex workflows.

This example form allows an interoperating system to create a patient with some common fields: patient_name, age_in_days, phone_number, and an id in the external system. In this example, location_id is used as the parent_id field; this field will usually have to be configured in a custom mediator.

Field	Description
`patient_name`	Patient’s name.
`phone_number`	Patient’s phone number.
`age_in_days`	Patient’s age, in days.
`sex`	Patient’s sex.
`external_id`	The preferred identifier from the external system.

{
  "INTEROP_PATIENT": {
    "meta": {
      "code": "interop_patient",
    },
    "fields": {
      "age_in_days": {
        "labels": {
          "short": {
            "en": "Age in Days"
          }
        },
        "position": 0,
        "type": "integer",
        "required": true
      },
      "patient_name": {
        "labels": {
          "short": {
            "en": "Patient Name"
          }
        },
        "position": 1,
        "type": "string",
        "length": [
          1,
          40
        ],
        "required": true
      },
      "phone_number": {
        "labels": {
          "short": {
            "en": "patient Phone"
          }
        },
        "position": 2,
        "flags":{
          "allow_duplicate": false
        },
        "type": "phone_number",
        "required": true
      },
      "location_id": {
        "labels": {
          "short": {
            "en": "location_id"
          }
        },
        "position": 3,
        "type": "string",
        "length": [
          1,
          60
        ],
        "required": true
      },
      "external_id": {
        "labels": {
          "short": {
            "en": "External ID"
          }
        },
        "position": 4,
        "type": "string",
        "length": [
          1,
          60
        ],
        "required": true
      }
    },
    "public_form": true
  }
}

Using the above example form, this transition will create a patient document and add a birth_date field using patient_age_in_days.

{
  "form": "interop_patient",
  "events": [
    {
      "name": "on_create",
      "trigger": "add_birth_date",
      "params": "",
      "bool_expr": "doc.patient_name"
    },
    {
      "name": "on_create",
      "trigger": "add_patient",
      "params": {
        "parent_id": "location_id"
      },
      "bool_expr": "doc.patient_name"
    }
  ]
}

Inbound Reports

Encounters and Observations created by interoperating systems can be sent to the CHT to be visible to CHT users. Similarly to patients, a mediator converts the FHIR resources to a json format that is submitted to the records API. Reports need to be linked to patients using a patient_id field which is the uuid of the patient document in CHT. The mediator extracts this id from the CHT Document ID identifier of the FHIR Patient. For patients created by CHT, they need to have been sent to the interoperating system before receiving any reports. For patients created by the interoperating system, the CHT Document ID needs to have been set; see the section below on Patient Ids.

A CHT form needs to be configured to receive the reports via the records API. In the form configuration, the names of fields which should be extracted from Observations should be the codes of the Observations. Human readable labels can be added for display.

Because these forms are CHT forms like any other, messages, validations and other transitions can be assigned to them to build more complex workflows.

This example configures the form for a typical antenatal care form.

{
  "INTEROP_ANC": {
    "meta": {
      "code": "interop_anc",
      "translation_key": "forms.interop_anc.title",
      "icon": "icon-anc-followup"
    },
    "fields": {
      "patient_id": {
        "labels": {
          "short": {
            "en": "Patient Id"
          }
        },
        "position": 0,
        "type": "string",
        "length": [
          1,
          13
        ],
        "required": true
      },
      "17a57368-5f59-42c8-aaab-f2774d21501e": {
        "labels": {
          "short": {
            "en": "Danger signs screening"
          }
        },
        "position": 1,
        "type": "string",
        "length": [
          1,
          20
        ],
        "required": false
      },
      "1427aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa": {
        "labels": {
          "short": {
            "en": "Date of last menstrual period"
          }
        },
        "position": 2,
        "type": "string",
        "length": [
          1,
          60
        ],
        "required": false
      },
      "5596aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa": {
        "labels": {
          "short": {
            "en": "Estimated date of delivery"
          }
        },
        "position": 3,
        "type": "string",
        "length": [
          1,
          60
        ],
        "required": false
      }
    },
    "public_form": true
  }
}

Populating Ids.

When patients from an interoperating system are sent to a CHT application, the mediator needs to maintain a link between the CHT patient and the external patient by saving the document and patient ids from CHT, and forwarding them back to the interoperating system. Because the patient document is created aynschronously with the request to create the patient, the mediator exposes a callback endpoint to add these ids asynchronously.

To use this endpoint, create another outbound push config with patient_id and external_id, and relevant_to being doc.type === 'data_record' && doc.form === {{the code of the patient creation form}}.

The mapping contains three fields, id, patient_id, and external_id.

Field	Description
`_id`	Id of the report document that created the patient. This is used to retrieve the patient document, but is not directly the CHT document ID that will be used.
`patient_id`	The patient_id from CHT.
`external_id`	The external id which will be used to create the link between the cht and external patient.

{
  "patient_id": {
    "relevant_to": "doc.type === 'data_record' && doc.form === 'INTEROP_PATIENT'",
    "destination": {
      "base_url": "http://openhim-core:5001",
      "path": "/mediator/cht/patient_ids",
      "auth": {
        "type": "basic",
        "username": "interop-client",
        "password_key": "openhim1"
      }
    },
    "mapping": {
      "doc._id": "doc._id",
      "doc.patient_id": "doc.patient_id",
      "doc.external_id": "doc.fields.external_id"
    }
  }
}