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1.11 Appendix: HL7 EHR Functional Model and FHIR

The HL7 EHR System Functional Model provides a reference list of functions that may be present in an Electronic Health Record System. While FHIR is an implementation focused on exchange of information in healthcare, this often happens in the context of an EHR. This table briefly describes one way that FHIR can be used to meet the requirements described in the EHR-FM and is provided to help readers of the FHIR specification understand how FHIR can be used. There are many other equally valid ways to implement the EHR-FM and to make use of FHIR.

EHR Function FHIR Implementation Notes
IN.1 Security FHIR defines parts of the security infrastructure, and delegates others to standard web based security frameworks
IN.1.1 Entity Authentication FHIR assumes that the users are authenticated. OAuth is the preferred mechanism
IN.1.2 Entity Authorization FHIR does not currently provide any resources to describe or manage access-control permissions. By default, underlying web frameworks such as SAML would be used. See the security section for a discussion of binding between FHIR and SAML
IN.1.3 Entity Access Control See above about SAML / OAuth
IN.1.4 Patient Access Management See Security Labels
IN.1.5 Non-Repudiation The provenance resource tracks the timestamps, actors, digital signatures associated with resources
IN.1.6 Secure Data Exchange TLS (https:) should be used for all production exchange of data. All conformant FHIR RESTful implementations SHALL be able to use https
IN.1.7 Secure Data Routing FHIR allows for brokers and various forms of messaging that support assured destinations and delivery (also see IN.2.2 below)
IN.1.8 Information Attestation See the provenance resource
IN.1.9 Patient Privacy and Confidentiality FHIR does not include functionality related to this requirement, though implementations would be expected to provide this
IN.2 Health Record Information and Management This is a core application of the FHIR capabilities
IN.2.1 Data Retention, Availability and Destruction A FHIR RESTful server gives precise and fine-grained control of retention, availability and destruction of resources, all clearly described by the conformance statement
IN.2.2 Auditable Records FHIR provides the SecurityEvent resource for auditable records.
IN.2.3 Synchronization FHIR supports synchronization using standard web publication/subscription methods via Bundles (i.e. Atom feeds). Atom-based pub/sub may be push or pull based, and can include all resources of a particular type, or selected subsets of the resources. In addition, groups of resources can be exchanged in bundles, keeping a set of related resources in synchronization
IN.2.4 Extraction of Health Record Information FHIR does not provide report formats, but does provide extensive search and retrieval functions to assist with building such reports
IN.2.5 Store and Manage Health Record Information A FHIR RESTful server can store and manage health information persistently - see below for further information.
IN.2.5.1/2 Manage Structured and Unstructured Health Record Information The dual contents of FHIR resources - structured data and XHTML narrative - provide seamless support for dealing with a mix of structured and unstructured information
IN.3 Registry and Directory Services The FHIR Administration resources provide a registry based access to patients, providers, etc.
IN.4 Standard Terminologies and Terminology Services FHIR encourages the use of standard terminologies wherever possible, and provides full support for their use through a variety of terminology related data types . FHIR does not define a terminology infrastructure or service, but does define the Profile and ValueSet resources to describe how terminology is used in a FHIR context
IN.5 Standards-based Interoperability FHIR is a definition of a standard on which to base interoperability
IN.5.1 Interchange Standards This is the core focus of FHIR. See below for discussion of interaction modes
IN.5.2 Interchange Standards Versioning and Maintenance FHIR version maintenance is described here
IN.5.3 Standards-based Application Integration FHIR enables simple integration through use of an easy to understand, use and debug web-based infrastructure. The same framework used within an EHR for persistence can also offer a simple way to implement exchange
IN.5.4 Interchange Agreements The FHIR Conformance Statement and Resource Profile resources provide a registry based infrastructure for individual trading partner agreements, as well as for community based ones
IN.6 Business Rules Management FHIR does not address this requirement at this point in time
IN.7 Workflow Management FHIR does not address this requirement at this point in time, though the resources and services exist to support this functionality

The EHR functional model describes several modes for interaction between systems. Each of these can be implemented in several different ways using FHIR

Interaction Modes FHIR Options
Unsolicited Notifications
e.g. a patient has arrived for a clinic appointment
  • create/update new resource via http
  • push resources using atom
  • Send FHIR Message (if appropriate event is defined)
Query/Response
e.g., Is Adam Everyman known to the system? Yes, MRN is 12345678.
  • search with parameters
  • A query message (though not defined yet)
Service Request and Response
e.g., Laboratory Order for Fasting Blood Sugar and a response containing the results of the test. 		Could be supported either through Messaging or SOA solutions. Request/Response support is not yet defined
Information Interchange between organizations (e.g. in a RHIO, or in a National Health System)
  • pub/sub using atom (push or pull)
  • RESTful interface
  • FHIR messaging
Structured / Unstructured clinical document, e.g., dictated surgical note See the Documents

The combination of a properly secured and managed FHIR server, along with enforced use of the SecurityEvent and Provenance resources ensures that the core record management functions defined in the EHR-FM are met:

Additional functionality, not defined at this point in time in FHIR, is required to ensure non-repudiation, access control, and consent tracking.

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