eCR Now FHIR App

Introduction

A production version of the eCR Now Fast Healthcare Interoperability Resources (FHIR) App and its source code are now available for electronic health record (EHR) companies and other implementors to download and implement. The app provides COVID-19 electronic case reporting capabilities for EHRs that, before now, did not have them. It can also be configured to do full electronic case reporting for a full set of reportable conditions when COVID-19 is a diminished focus.

The app is different from many commercial apps in both its attributes and provisioning. It was designed to be implemented now and work with the substantial infrastructure that is in place for electronic case reporting (eCR). The eCR Now technical team will partner with implementors that choose to use the app, but the team will not be hosting it or processing it through all the different EHR app stores.

This page provides context and lays out the planned process and communication channels to use the eCR Now FHIR App to meet the critical eCR needs of the COVID-19 pandemic.

The current version of the app and its source code can be found here:

GitHub App Source Code (external link)

Context

eCR involves the automated identification of reportable health events in EHRs and their transmission to state and local public health authorities for review and action. Reporting is a legal requirement for COVID-19 and many other conditions, but the specific laws vary by state. Triggering case reports out of EHRs does not, by itself, definitively establish that something is reportable or which public health agencies should receive it if it is.

To address the complexity of reporting requirements, the Centers for Disease Control and Prevention (CDC), Council of State and Territorial Epidemiologists (CSTE), and the Association of Public Health Laboratories (APHL) have implemented shared eCR services on the APHL Informatics Messaging Services (AIMS) platform, including provisioning, decision support, routing, and delivery infrastructure to provide electronic case reports to public health agencies for integration into their surveillance systems. The eCR Now FHIR App is constructed to connect to, and take advantage of, this existing infrastructure to support appropriate reporting, even though neither it, nor public health agencies, currently support production Health Level Seven International (HL7) FHIR services.

Electronic case reporting data flow visual, from provider’s electronic health record to public health

Implementation

The eCR Now FHIR App is intended to run as a background process during patient encounters and report automatically to appropriate public health jurisdictions and their surveillance systems though the AIMS shared services infrastructure. In this way, it should not burden or disrupt healthcare provider workflows. On the EHR side, the app is built to leverage the work of the Argonaut Project, HL7, and the Office of National Coordinator for Health Information Technology, work that has advanced the FHIR APIs that are now implemented in EHRs.

The app supports HL7 FHIR DSTU2 EHR access because that is the level of FHIR API that is in many installed EHRs. The app also now supports HL7 FHIR R4 because some EHRs now have that API implemented and it is more robust from a data access standpoint. The app can also be made to use HL7 FHIR STU3.

On the public health side of the app, it produces an HL7 Clinical Document Architecture (CDA) Electronic Initial Case Report (eICR) 1.1. This is the initial case report standard that can be received by the AIMS shared services platform, processed by the Council of State and Territorial Epidemiologists' Reportable Conditions Knowledge Management System, and then integrated into the public health agency surveillance systems or rendered for them in viewable HTML documents.

Other app attributes include:

  • By configuration, the app can do full electronic case reporting in addition to COVID-19.
  • It produces fully validated, outgoing HL7 CDA eICRs v1.1.
  • It includes transport out to the AIMS shared services platform:
    • Included support for Direct
    • An interface for XDR and other transport
  • It receives and sorts the returned Reportability Responses to identify those that should be notified to the provider of record and attached to the patient’s chart from those that support EHR system administration needs.
  • It consumes up-to-date trigger codes and reporting parameters from the Electronic Reporting and Distribution (eRSD) system, minimizing health system and EHR trigger code management.
  • It provides local storage of eICRs that have been sent.
  • It supports automated launch possibilities for complete background operations:
    • No user interface SMART on FHIR app launch
    • System API launch when provided with patient ID, encounter ID, FHIR Server URL
  • Can trigger on all of the following:
    • Lab orders
    • Lab result test names
    • Lab result values
    • Conditions in problem list
    • Conditions in diagnosis
    • Medications

Teaming and Release Process

If an EHR presents a capable FHIR API, app implementation is not difficult. At a recent HL7 FHIR Connectathon, all participants that tried to implement the app were successful, even though they had possession of the app for less than a week.

The eCR Now App is being developed with the intent of its sharing, with its source code, for implementation by EHR vendors and other implementors. The first production release of the eCR Now app occurred on June 3, 2020.

Next Steps

  1. Access the app and source code from the GitHub site.
  2. Download and implement the app in your local development sandbox following instruction on the GitHub site.
  3. Verify that the app runs successfully in your local development sandbox.
  4. Post any issues or question to the Zulip chat channel.
  5. Add COVID-19 data into your development sandbox EHR for testing purposes and test all of the different triggering circumstances.
  6. Connect with the eCR team via the eCR-Info@aimsplatform.org early to plan an onboarding and coordination process.
  7. Continue to check here for subsequent app updates.

 

Communication Channels and Resources

eCR Now App Discussion on Zulip (external link)

Electronic Reporting and Surveillance Distribution System (eRSD) (external link)

GitHub App Source Code (external link)