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so this is the CC on fire truck also known as the fire documents track I'm Rick gamer I work at Lantana Consulting Group and the chief innovation officer there and a lot of folks know me from hl7 I work in the CDA Management Group I'm a member that also fire infrastructure used to be a co-chair of the structured documents workgroup and when I've got any spare time I'm in the attachments workgroup for HIPAA attachments basically I work for Lantana Consulting Group were a healthcare services company do a lot of work for CMS CDC and also private clients as well helping them do strategy converting data things like that so today what we're gonna do is we're gonna start with an overview of clinical documents or electronic clinical documents I should say we're then gonna show how they are represented in fire we'll talk about the fire document paradigm and how it works then we'll dive into the CCD on fire specification which is a new US realm implementation guide that's meant to basically represent the ccda or consolidated CDA use case using fire resources and we'll also talk a bit about the u.s. core project since the CCD on fire is heavily dependent on it we'll wrap up by talking about converting managing and validating fire documents and then we'll talk a little bit about future work that's going on so clinical documents you can find them all over again medical record you can get old paper-based documents that maybe you've scanned into PDF and such you can have consolidate C or C CDA documents that can bring up and display using various style sheets you can actually represent things like calm diagnostic structured you know reports as clinical documents and you can bring them up and browse them on your slightly old iPhones if you wish my point is that there's clinical documents are all around us now they're used every day they populate probably the majority the patient chart and a lot of people don't only think about them and how they work so clinical documents have several key characteristics that differentiate them from messages or things like typical restful queries and such the first of them is persistence clinical documents are meant to be kept over time they're meant to persist they're a permanent part of the patient's record if you think about the paper world when you know clinicians sometimes I still do but carry around those old manila folders with all those documents in them they've you know written up and signed they can't just throw those out at the end of the day okay they're a permanent part of the patient record often there's legal retention requirements around there something like seven years and such just because you take those and move those into the electronic realm those requirements don't go away so when you start thinking about processing clinical documents remember that you need to find a way to store them as well they shouldn't just be generated and just thrown out if you're something's gonna be persistent then you also need someone who takes responsibility for keeping copy of that that's called the steward or custodian of that document it's the organization that's maintained with its care probably the most important one on this list characteristic is the potential for authentication clinical documents are meant to be signed in other words are things that clinicians will attach their signature there that all attest to the content that within them so if you see something that carries a clinician signature on it be it a real wet signature or an electronic signature of some kind there's a good a good indication that it might be a document and not something ephemeral like a message context so a clinical document establishes its default context for its content in the old you know I say the older the sort of current hl7 version 3 based CDA that's called the header of the CDA document it has things like what kind of document is it is a history and physical or you know procedure note or something like that it'll say who the patient is who the author of the document is what time it was created all that type of stuff sets context so that you can get an idea of what's coming next sort of paired with that is that concept of wholeness so clinical you wouldn't use a clinical document just to exchange somebody's blood pressure and nothing else rather you would use that to exchange maybe a history and physical that includes their full vital signs vital signs that a bunch other information as well so they tell a whole story usually about an encounter or summary of care over a period of time and lastly is human readability documents are meant to be read by people certainly there's a ton of coded information in there when you move into the electronic realm so that machines can also process them at the end of the day every clinical document has a human readability as a sort of a fallback and this becomes important when you're talking about exchanging documents among systems or organizations with different levels of sophistication let's say that you've got a very high-end EHR you've your organization has spent a lot of money investing in sno-med and link and can do all these great complex coatings but then you send that document to an organization that is really just a mom-and-pop shops maybe they don't have any of that sophisticated terminology mapping they wouldn't know what those codes mean but they could always open it up in a web browser with a style sheet and display it so human readability is that sort of key level of interoperability that very base level which is eyeball interoperability so to talk about electronic clinical documents going to give a very brief history on CDA or clinical document architecture as it's known so this is a specification for defining electronic clinical documents it's a ANSI and an ISO standard and it's the base standard on which many of the implementation guides that are exchanged today like for Meaningful Use and such are our based so if you've done consolidated CDA or Quality Reporting or any of those types of things they're based on CDA so just quick show of hands how many folks have worked with CDA or consolidated CDA before quite a few I guess the that's why the title of this tract was attractive to you consolidated CDA is probably the most popular CDA implementation guide out that's out there it contains about a dozen different document types its impetus or the reason why it was created because we originally had a whole bunch of single implementation guides like for a consult note or history and physical and such and cognitive care document or CCD in fact and then different organizations went around and customized those implementation guides so we ended up with like different versions of ccd floating around and then one of those organizations hits me just decided to disappear one day and left no one really in charge of maintaining that so 8:07 took up the charge and worked with other organizations with hit speed with ihe with the health story project and brought all this back together into one single sort of master implementation guide for primary care so if we've got C CDA and people are exchanging documents with that today you know what can be improved why change it so I like to start off with what I call Graham's law he doesn't call it that but you know Graham grieve the father of fire he's got a lot of great sayings the one of his that I probably like the most is that you can hide complexity or make it worse but you can't make it go away CDA and hl7 version 3 in general was a lot more complex than necessary things that should have been simple technical problems like just exchanging a date became difficult roadblocks for miners because of course the date format that hl7 chose for Version three was different from what everybody else uses you know little things like that that caused you to waste you know few hours of developers time but then you multiply that by dozens and dozens and and it becomes you know we can eat up your budget very quickly so even though CDA was sort of state stable and simpler than the rest of hl7 version 3 and saw more widespread implementation it inherited much of that complexity and it never had a viable API component was really just a standard for here's what you know electronic documents look like an XML didn't tell you how really how to send it and such those were all you know there are a bunch of related standards out there like um you know I cheese XD XD s specifications direct messaging things like that but those aren't really sort of built and it was never tightly coupled to the standard so fire in my opinion makes simple problems simpler again alright so you get to use you know restful api is that are familiar with folks you can use XML or JSON the data types for the right ones finally so you can just sort of pick stuff up and start going there's lots of reference implementations out there from day one so you don't have to waste a lot of time working on those simple things and you can get to the hard problems quickly like terminology which is fire does not make easier by the way you're dealing with sno-med and in terminology map ending on rxnorm and all that you want to get to those hard problems fast because that's where you want to spend your budget on because again fire won't solve that for you another reason why I like fire for clinical documents is that many CDA's exchange today in my opinion or just EHR thr data dumps you know everyone implemented the consolidated CDA spec according to meaningful use rules and they just decided to take everything their HR about a patient and dump it out into a CCD or you know one of those other document types and you know show up it along from a one EHR to another what I hope to see is that you know if really the goal is to just get you know all the information that you want about a patient or get just a specific piece of data instead of having to send everything you know over the wire back and forth you can use fire queries for that same purpose or something like fire bulk data much more efficiently they can you see CDA or even fire documents so my hope is in the future we'll get away from those kind of data dump documents you know I would be you know super happy if the CCD document type just went away completely I never want to see him again and we get things like history and physicals procedure notes progress notes that are actually clinically relevant so I hope to see a lot more clinically relevant documents and less of those data dump ones in the future and I think fire can get us there because it's got a better way of managing that sort of bulk data use case so uh don't really this is def days we don't really need to talk about this everyone knows a fire is I always throw up this Lego analogy slide mainly because whenever anyone did this in the past I would hate it I would look at a standard and they'd make a lego knowledge I think how really is it that easy but this is this is the first one where I actually feel you know it actually deserved it so I I'm the guy now putting up the Lego analogy slide you know basically resources or blocks you can assemble them into bigger contracts like documents or bundles and you can operate on them much like Lego Mindstorms using fire api's so there are some similars and differences between fire and CDA so some similarities are that they they both support profiling for specific use cases and CDA we call that template not not profiling but it's basically the same thing you're doing things like making something that's optional required or making something that's repeatable limiting it to a single one or binding things to specific value sets both have human readability as a minimum standard for interoperability so every fire resource can have a text property that is H XHTML and there's validation tooling and profiling tool available for both some key differences though and this first one is a little bit controversial some people don't agree with me on it but fire you can pretty much use out of the box and I put some quotes around that out of the box what I mean is a developer can pick up the fire spec some of the the fire reference implementations and start you know doing something meaningful with it right away without creating profiles or even using profiles it's hard kind of hard to do that with CDA because it's so generic and so broad but fire has already specific resources like you know how allergy and tolerance and such condition that CDA never had they just have the generic observation and you really had to if you wanted to express an allergy create a template on observation that told you how to use it for an allergy use case fires got a lot of that already baked in the only thing that's not only baked in in many cases are the terminologies that you want and the base resources make everything pretty much optional so that's why I say profiling is still recommended but not necessarily required just to get started and doing something useful fire also encompasses a lot more than documents you can you've got discrete resources you can do messages you can work with the api's so there's a lot more to the fire spec than just how do you represent documents in XML and lastly implementer tooling is generated with a spec in fire it's very tightly coupled with it generated during the build process including that validation tooling and such so the the coupling to to everything around that you need to create and use fire is much tighter than it ever wasn't CDA and CDA a lot of that came after the fact so fire documents let's talk a little bit about them so fire documents address the CDA use case for clinical documents and they're represented basically using thing called the composition resource you can think of that as the equivalent of the CDA header plus the human readable narrative all in one resource it's a single discrete thing that can be signed and tested too but the cool thing is that composition resource can also point to just about any other resource in the fire spec to hold its coded data and then you would send that basically wrap that using a bundle resource and send it along from one party to another clinical documents in fire or fire documents I should say can be signed and authenticated just like in CDA and a fire document has the same basic obligations so if you remember those key characteristics like persistence and such they apply to fire documents as well in fact one thing to think about when you're dealing with fire documents I mean a lot of people work on fire servers and you know one day the fire servers up next day it's down one advantage of using fire documents when you bundle them up is you do get a complete package of everything that was that you created about that patient at that point in time and you can send it from you know point A to point B you can store it in a document management system do whatever you want in fact I liked and to note that the clinical documents regardless of the specification they're created on often outlive those systems okay so when you start thinking about things like like fire versioning and such like that and bringing servers up and down having a persistent format that's gonna you know stay around for a long time is key so here's a quick slide on how a fire documents look it's sort of an abstract sense you've got let me see if I can get my mouse over here you've got your composition resource and this has all the sort of basic metadata about the document like what kind of document is the point code for it what data was created who the author is and such you've also got information about who the ax tester is or who's signing this document in CDA would call that the legal Authenticator then you've got a series of sections and those sections can nest but in practice they usually don't in the US and those sections can then point to various discreet resources to Kanton to contain all that coded information those sections themselves also contain narrative mark in xhtml so basically when you bundle all that together you get a bundle resource with a series of entries the first one being the composition resource which then points to everything else so the composition resource contains information about the patient the author the custodian or the steward of the document and all that type of stuff you can think of it as being sufficient for locating records for records management document management and such and there's a lot of search properties on the composition resource to help you find documents so you can search for you know for instance I want you know the patient's most recent history and physical that's right you don't have to do anything custom to do that using fire documents all those search properties that you need for that are already built in the composition resource so every fire server can let you build systems that are bright lad a lot like that very quickly so sections a narrative in the composition resource a couple things about it first of all the narrative markup is XHTML unlike CDA CDA had its own sort of proprietary a markup language for for the human readable content and fire it's just XHTML so if you've already got a system that maybe as a web-based EHR you're used to generating HTML that knowledge transfers directly into fire so when you're making fire documents you don't have to worry about oh the the P tag is actually called paragraph or something like that like you deal with CDA so the narrative contains the attested text of the document in other words when the clinician signs a document it is what is what you put in they are signing what you actually put in that text or in that narrative markup so other words are not signing the sno-med codes that are you know in the observations that you make they're signing the actual text that you've shown them on screen that they're reading so one thing to be aware of make sure you populate when you're creating your fire documents that you populate that narrative section especially if you're talking about signed documents so it is also okay for sections to consist only of human readable text so you don't need to have you know coded resources in your fire documents there are many use cases for narrative only documents but obviously you know the ones that folks I think are used to sharing today to qualify for meaningful use do require a large amount of code or data so that's certainly still there that's certainly possible but there are other use cases for things like administrative notes and such or there's not a lot of value to coding or potentially whether it's just simply no codes exist for what you want to represent so just something to be aware of so the way narrative markup are sections look in fire is pretty much like this we've got a example section with the title of allergies and intolerances we have a link code down below which actually shows that's the allergy and intolerance section and that's the exact same one code that would appear in a CDA document with an allergy section if we scroll down a little bit we then see text with some XHTML in it in this case we've got a bulleted list or unordered list with penicillin - hives and if you were to take that take this whole section and bring it up in a web browser render it with a style sheet it would look kind of like what we got over here on the on this far side you'd have allergies intolerances title and then penicillin - hives alright so a human can look at that and pretty much tell oh you give this person penicillin they get hives as the reaction but to make this computable you want to use something in this case the allergy and tolerance resource so here we've got the allergy intolerant resource up at the top we've got the code which is allergy to penicillin and then over here we've actually documented the reaction which is hives so this is basically in your composition resource you'd have this page up in the composition resource is the section eret of text and then right below it you'd have a reference to the allergy and tolerance resource which is how a computer would process this right so enough about fire documents in general let's talk about the CCI on fire specification so this is a US Rome implementation guide it is fairly new it was just published in April of this year it had been in work for quite a while its first first ballot was actually in September 2016 it's just a for comment ballot just to see if anybody was paying attention or interested but it's real first ballot as a standard for trial use for s tu was January of 2017 and then we spent the better part of a year trying to get it working you know I would say out of that time you know probably about three months was spent on ballot reconciliation and then the rest of the time was trying to get the fire IG published or tooling to work anybody's done that it can be quite painful but we did finally get it out it is up there now basically it's a goal is to create fire profiles for the consolidated CDA use case and to do that we decided we weren't going to reinvent the wheel we weren't going to create all our own profiles for every template that's in CDA rather there is our what we call sort of a sister project there the US core project which was which was already going through and creating fire profiles for the common clinical data set or CCD s so we just kind of put a stake in the ground and made an early decision that any for any CDA templates for which a closely equivalent could be found close equipment could be found in u.s. core we were just going to use it all right and for anything where there's a CD a template for which there was no profile created with US core we weren't going to do it rather what we would do is we would provide guidance on what unpro filed resources could be used and we pretty much stuck to that I think we ended up making one or two additional profiles but not much and actually we haven't heard a lot of complaints so far because I think US core actually covers a lot I know Emma's gonna raise you're gonna raise your hand because you've got a couple complaints I think but right yeah yeah correct so I'm not saying we aren't gonna go and do that but to get that sort of first shot across the bow and get a usable specification out there that's what we did and we understand there's a lot of things that you know for which again having a firm profile us-run profile would be great certainly as we go further on I'll talk about the CDA - fire mapping project which is just started last month we'll be addressing a lot of those during that project so this is a first s to you to get it out there and have it get some trial use going on and like I understand what we're talking about is you know the 80% the US Corps represents maybe he's not everybody's 80% but it was a good enough where we can do we can get this out the door without you know you know a major funding it was actually no funding behind this project it was all volunteer effort so so where do you find CC on fire so if you want to find it you can go to the fire homepage and then scroll down to the very bottom and you see where it's sort of highlighted in red here this thing is as implementation guides so you just click on that first link down below that says published by hl7 fire foundation etc and you'll find a page will come up and it'll have US Corps up there I think like the third one down is CCD on fire you can also just use these links that I've got up at the top there is the publish specification and the current build right now they are pretty much in sync because this was just published in April and we haven't made any updates since then but that will be changing probably over the summer certainly by the fall as the CDA to fire mapping project that I just talked about and gets underway so a little bit about the US corporate framework so as we mentioned US cores based on the common clinical data set and it contains many of the things that are required under exchange and CDA documents that we see today you know things like problems allergies medications lab results so all that type of stuff is present there are a few things that are that you would expect to be there that aren't aside from what Emma mentioned you'd also notice that there's no US core encounter profile well some of those are working on their adding others they've just said are gonna be out of scope for us core so there will be stuff that will need to be added but in some cases may those can again we haven't found anything that can't be at least that's in common use in CDA documents today that can't be at least represented using a known profile fire resource where there is no us core one yeah yeah sure the reason why we didn't do that um that this goes back to a little bit of history the earlier version of the composition resource actually did not have a list of entries in it but we actually had done for fire DST u2 was we brought in the properties of lists into the section element in the composition resource itself so section has you know star entries and all the properties of the list resource so you don't actually need one you don't need to do that double wrapping where you've got a section the points to a list and then pulls in the meds you can just include them directly but you know there are some people who still want to create lists of lists in some cases so we don't prohibit that but just you know that's kind of the approach that we went so let me go ahead and quickly drop out of here and I'll give a brief overview of the spec itself actually should have got the lavalier mic for this now cuz they'll have to be driving with one hand I think I can manage though so here's the fire you know current published spec or you know the stu3 so you can click on here and you get the fire illumination guide registry and then next you can just go right here and see CC on fire and I'll note all the versions that are out there the one that you're interested in is the current version St you won this first page here just gives a bunch of background information on the spec itself talks about using us core as as the 80/20 and and and so on and so forth but really where you want to go to is the profiles page so here we've got a series of profiles the first of them is the us realm header now folks who are familiar with consolidated CDA know that there's a US Rome how US ROM had her temple which is sort of the base for all these specific document types in consolidated CDA we took the same approach with CC on fire so in other words we created a US realm header profile on the composition resource it's meant to be an abstract profile so this one you wouldn't actually implement directly rather it's the base profile for which others are derived and it does things like create some extensions that you want to use for things like you know who the data enter is the informant information recipient these are some properties that are not present in the core composition resource mainly because composition is a little more generic than the CDA spec CDA was laser focused on clinical documents whereas the composition resource can be used for any kind of document it can be used for catalogs or durable parts and such so there are some properties of clinical documents that weren't considered to be part of the you know 80% for all documents that could be you could talk about in healthcare so and those case we created some standard extensions for them so you can go down and see those present then we've also done things such as we bound the subject to a u.s. poor patient or a group we bound we bind the author to the US core practitioner or practitioner role or also for things like us core patients for patient author documents and such also devices if you wish to have a device author document then we go down and make sure that you've got at least one you know if you're gonna have an a tester that is a you know has legal responsibility that there is one of those present and then you can also have professional personal signatures as well personal one for instance would be for a patient author and patient signed a document okay so from there you can then go that down and see the various profiles for the different document types that are present so in this case I'm just gonna bring up the continuity of care document and this one here if we scroll down and look at its differential table it looks a lot smaller because as you see here this is derived from the US Rome header so everything that's in that header applies to this one so all you're seeing in this differential is are the differences between the u.s. Rome header in this in this case we bound the type to this code from link that's the code for summarization of Emma so of episode note we've required that you have a service event showing the start and end periods over which you're summarizing this patients care and then we have a series of sections like allergies and tolerance medications and such in other words exactly the same sections that you would with the same requirements or cardinality that you would see in consolidated CDA in the old CDA based based spec but the difference you'll notice here is that where we talk about the coded entries now we've got references to other us us core profiles like the US core medication statement u.s. core condition for the problem section and he can go down and sort of see that you know throughout so these are you know active lengths so you can actually go here and click and go directly to the US course back and see the US core condition and everything that's required on this click on its differential and you see that it requires a code that's bound to the problem value set and subject is a reference to u.s. core patient so we've tightly integrated these two specifications together so you can click from one to the other pretty easily right and I think that's about it for this there are several you know again we've defined some extensions we able to read more about them here you can we do have a section descriptions page so if you want to go on to quickly see you know what the encounter section looks like you can click on it you can get the encounter section and see where it's used so this just provides some good navigation around especially if you're familiar with CDA and you want to see how and where something's represented using CC on fire alright so let's go back to the presentation make sure I'm doing ok on time I think I got about 10 or 15 minutes left all right so converting from cease CCDA to CC on fire first of all you might want to ask why if we got a usable spec up there why do you want to convert well my opinion it's currently you know while EHRs fire api's are still kind of maturing whereas their CDA export is quite mature and quite robust for me it's a critical way it's a way to get to a critical mass of fire documents or just raw fire content yes I can go to you know at the concern er and hit their fire api's and get you know patient a problem a few other resources out there but if I grab one of the receipt uh you know C CDA documents and convert it to fire I can actually get a lot more data today then I can through their fire api's now that's changing I hope it changes faster but until then that this could be a good way to get a lot of fire contents it also you can also think about fire documents as providing continuity with existing practice but with better syntax and api's and one of the big ones though that I like is that software developers a lot of them when I show them CDA and fire maybe giving them training on both if they don't have an existing CDA infrastructure they immediately gravitate towards fire because it's just simpler you know bottom line so what I found is you can often teach developers how to create fire documents much easier than you can to create CDA documents and then you just need a one conversion script you can train you know hundreds of developers but you give them a single conversion script that goes from a fire document to CDA and then bam you end up with you know all the CDA documents that you need to comply with it today's regulations they're a lot more consistent and you the developers don't waste their time learning you know what you know I won't call it an obsolete standard which maybe in a few years that's still heavily in use but certainly a momentum is moving towards fire in a way for Supreme CDA at this point um so there's a you know lots of ways you can convert from CCDA to fire and fire to CDA today most of them are either you know open source or some proprietary solutions that re out there there is however just basically starting in May we started a CD ACCA to fire mapping project in hl7 so its goal is to create definitive mappings hl7 sanctioned mappings between CDA and fire using fire mapping language so that's using things like the structure map resource and such so this just just got kick-started we had a first demonstration of some some very primitive transformations in at the May working group meeting so the this is not expected to be complete until September 2019 at least according to the current project scope statement so I wouldn't say it's something that's easy to use right away right now but it certainly where we're headed and but for now if you do want to use it again there's a bunch of solutions out there the one that I ever worked on is called it's for basically converting pharmacist care plans that was the use case for it but it actually handles a lot more as well so that's available up at github that one is using XSLT again but moving forward we'll be going to the fire mapping language that I mentioned previously so for managing documents fire documents basically are persistent objects as I said at the start so you need to store them somewhere the easiest place to put them is simply at a fire server so fire documents are bundle resources so you could store them at the bundle endpoint if you want to operate on them using all the search parameters and such for bundle if you want to treat them as just sort of immutable a persistent objects though you can also post them to the binary endpoint and when you do when you do that you can actually put your fire documents there you can put your old you know CDA documents there you can borrow PDFs pretty much anything you can put at the binary endpoint it is possible to also use document management systems if you want to take a fire document sort in the document management system you can clinical data repositories as well I've seen people just build their own databases from scratch and store more to store them in raw file systems so none of those are prohibited but again since they're persistent you should put him somewhere so for validating fire documents the easiest thing is just grab the fire validation tools that are provided with the spec so there are XML schema and schema tron files if you like doing I'm sort of the old way if you're familiar with doing that with CDA you've got the option to do those with fire as well they're not as complete though as the actual fire validator so the fire validator is a Java tool that you can use download and run and that will check you know all the bells and whistles of the fire spec you can also do you know profile validation against that as well so that's a recommended way to validate a fire documents again the scheme is in schema Tron we'll just sort of get you the basics also fire servers do validation so if you post a fire document for instance to the bundle endpoint and then you run the validate operation and you've got things like you know profile meta tags in there it will check them and make sure that you've actually followed all the rules so if you're using a fire server to generate your documents that's probably the way to go so a future work one thing that we didn't cover in ACCC on fire spec you know aside from the other 20% of stuff that wasn't in u.s. core were unstructured documents in other words things like how do you represent a scanned PDF file for those we purposely decided not to do that because we were discussing whether we should make a composition profile or a profile on the document reference resource for that since then the u.s. core project has actually picked that up and they've created a u.s. core document reference profile on the most recent ballot so basically we're just going to adopt that and use it and there have been several connect with on tracks now that talk about doing clinical notes that use the document reference profile for just that purpose there are some entry profiles like we you know like Emma was mentioning that are not covered by u.s. core so we expect that CCD air to fire mapping project to pick those up and start addressing them you know again by by the end of the project scope by 2019 you know September we hope to have mappings for everything that's at least you know you know really clinically relevant you know we understand there's probably a few profiles out there in CCDA that no one's ever implemented and probably never will so may not get to all those but the goal is that that anything that's actually been in use we do want to have profiles made for them that ideally map what was done in CDA at least in terms of terminology and cardinality other implementation guides will create as demand is is driven you know I mentioned that pharmacist care plan project that created a you know actually dual CDA and fire implementation guide simultaneously and made sure that they were in sync with each other and we created those transforms to go along with that there are also other implementation guides out there that that mirror what was done in CDA such as for electronic case reporting or healthcare associated infection reports as well so there's a lot of momentum around creating fire implementation guides for things that were previous previously CDA use cases and again that CD eight fire mapping project so in general you know question you want to ask yourself if you're moving to fire documents is you know it is your mode map you know on fire in my opinion fire basically evaporates hl7 version 3 messaging I know there are some folks in Europe who use it you're wrong in the US it never really took off and I think as we move towards towards fire there's less and less than II for hl7 version 3 messaging especially if you're bringing up new limitations obviously if you have something existing that's working don't just throw it out and that's gonna be the use case for hl7 version 2 as well you know a chosun version 2 interfaces or everywhere in the hospital they're not going away anytime soon in fact after the the the nuclear war and everything has gone except for cockroaches the only other thing left will be hl7 version 2 interfaces so they're not gonna go away but for CDA you know I like to think the fire retains the seat the core document concepts that were found in CDA and improves on text and data management and you have a unified model and syntax with messages and api's so CCI on fire again it's a standard for trial use just came out in April it's not you know everything not a guaranteed solution for everything you're doing the CDA today but it's ready for use and we are using an improv riot II of systems especially like I said sending these pharmacist care plans around we've tens of thousands of those in production use and they were actually working great but definitely more testing and more implementation is needed so folks who are interested in doing a document based exercise you know there's documents table-like like far in the back of the lunchroom there where no one can see it but I'll be there you know when I can certainly at lunch times and such and basically folks will just want to walk through some of the connected on tracks we've run probably about seven different fire document tracks at various hl7 connect a Thon's now so be glad to help people walk through those scenario and learn how to build documents if you wish and basically resources you know fire spec I think everyone knows where it is there is a white paper that's co-authored with myself Leo rush LaRon grant grieve on a sort of a position statement on on fire documents and and it became actually the basis for many of the changes that happened in fire ds2 you to and st to three to make fire documents really workable and myself i'm updated continuously rebooted occasionally usually around happy hour and uh take questions in just a second i wanted to very quickly though you know I mentioned CDA to fire conversion I actually wanted to just quickly demonstrate that so a couple minutes so here's an example of a CDA document so this is a 807 version 3 based XML and you can sort of scroll down and see you know it's got a patient their record target you can see their patient's name birth date you can also maybe that's C 706 1/8 yeah everyone's got the rxnorm quote for penicillin memorized right so you can scroll down and see their allergy information present so this is all hl7 version 3 CDA XML when I run this XSLT transform and convert it into a fire document now I've actually got a bundle resource with a composition on it you can scroll down it's got you know narrative based markup in XHTML I can see the document type which is the exact same as it was in CDA and I can also look down and so for instance find the subject if you follow these references you can actually see that they point to a in this case of patient resource that has all that patient information present the their name you know date of birth gender everything that was president the CDA document is converted over and likewise that same allergy this president that was President the CDA is now converted into an allergy intolerance resource so you've got all that coded information now present and it's safe to process outside of the document context since we actually preserve context we preserve who the patient is who asserted to this information all that type of stuff is brought over so this can now actually if you want to you can post it to the transaction endpoint of a fire server and break it apart use its component pieces yeah there is as well so if I were to take a fire document bundle in this case so this is a you know annotated sample of a pharmacist care plan let me just go back up to the top and I can convert this and make a compliance CDA document out of it as well okay so this now has a instead of a patient resource we have a record target with all this information in it now this was designed for the pharmacist care plan use case so everything that's needed in a pharmacy care plan like medications you know conditions allergies they're all in here doesn't cover all of CCD for instance but I've done did a lot of work with it approaching hims to actually cover quite a bit so it's there's it's it's useful quite useful I would say I know you had a question in there so go ahead yeah so there's a link to those transforms should be up here in the presentation or did I put that right well like Malik to the transforms or right so you can down those download those here so github.com slash Lantana group slash DHCP public transforms if you want to grab those it's basically XSLT with the Java driver around it and like I said it's it's useful until such time with that CD a to fire mapping project really takes off so right now this has quite a bit more coverage but over time we expect that to change yes how many EHRs have implemented that III don't know I'd have to ask ask EHR vendors I don't know if anyone that's implemented that conversion capability but again that's another reason why we create the transform so folks who want to start using fire documents can just convert back to CDA and send those and folks can process them as normal yes well again they're certainly the you know the Argonaut project and all that that are working on creating api's for them the question on when they're gonna bring up fire documents it's a little early again this spec just came out in in April and their time frame is usually a year or more in the future so you know certainly I would say start applying pressure if it's something you're interested in yes time alright well uh thank you all and hope you have a good day [Applause]