Immunization use cases cover three main areas requiring standardization:
- Messaging
- Terminology
- Single Sign On (SSO)
Listed below are the available standards considered for each standardization category, the chosen alternative being highlighted.
Document and Image Sharing
Foreign Exam Management will be implemented by an organization participating a jurisdictions’ shared Diagnostic Imaging Repository (DI-R) system. The DI-R will provide for registration and long term storage of sets of images and reports and standards based services that will be leveraged and, possibly, upgraded to support the FEM use case(s).
Messaging
The following messaging standards were evaluated to support the exchange of information between front end applications and Panorama.
Standard | Fit for PuposePurpose | Stewardship | Quality | ||||||||||||||
Fits | Implementation | Vendor Support | Canadian | SDO | Complexity | Standard | Training, Support and Tooling | ||||||||||
Pilot | IHE Cross-Enterprise Document Sharing - Imaging (XDS/XDS-I) | Yes | Production |
| NoMedium | Yes | Yes | High | High | Yes | DICOM / HL7 |
| Draft for Use |
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pan-Canadian Immunization |
| Production | High | No | Yes | Medium | High | Yes | Localized |
| Normative | Unknown | |||||
Architectural Constraints and Considerations | Secondary Benefits | ||||||||||||||||
FHIR’s modular components, foundation on web standards and support for RESTful architectures make the standard generally less complex and more accessible to developers of client applications than the pan-Canadian standards which are based on HL7 v3. | No notable secondary benefits. | None of these standards impose significant architectural constraints |
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Recommendation | Supporting Rationale | ||||||||||||||||
IHE Cross-Enterprise Document Sharing - Imaging (XDS/XDS-I) | The IHE XDS-I.b profile specifies the use of existing standards including HL7 and DICOM to enable registration and sharing of images and reports. A Canadian XDS Affinity domain guide is available to support implementation of the profile. | ||||||||||||||||
Note:
The IHE XDS/XDS-I profile builds upon the foundational HL7 and DICOM standards by identifying the roles of different actors participating in the information exchange and specifying how data exchange transactions and applicable standards enable document sharing. It also prescribes an affinity domain process that was employed by the Canadian Diagnostic Imaging Community to constrain areas of optionality in the IHE XDS/XDS-I profile to Canadian requirements. The XDS Affinity Domain Implementation Guide is the work product of this group.
Report Format
It is recommended that Panorama based new implementations adopt FHIR. | FHIR supports the use cases described above without further extension or localization. In the event that extension is required to support future requirements, FHIR provides a straightforward mechanism for creating extensions. Canada-specific terminology value sets can be used while remaining “FHIR conformant”, as the FHIR Immunization resource only specifies examples; implementers are free to use any value set they choose. FHIR has significant momentum among vendors and developers, meaning the long-term sustainability of FHIR-based implementations will likely be superior. There is a substantial ecosystem of open-source tools and reference implementations for FHIR that implementers can leverage to accelerate their projects. | |||||||
Terminology
The following terminology standards were evaluated to support the exchange of information between front end applications and Panorama.XDS/XDS-I supports a range of report formats through the use of different transaction and reporting
Standard | Fit for Purpose | Stewardship | Quality | ||||||||||||||
Fits | Implementation | Vendor | Canadian | SDO | Complexity | Standard | Training, | ||||||||||
Clinical Document Architecture (CDA) R2 | Yes | Limited in | Limited | No | Yes | High | Normative | Some | |||||||||
Portable Document Format (PDF) | Partial | Production | High | NoYes | N/ALocalized | Low | N/ANormative | Good | |||||||||
DICOM SR / SC | Partial | Production | High | No | Yes | Medium | Normative | Unknown | |||||||||
iTerm ValueSet | Custom | Yes | No | Raw Text | Partial | Production | Unknown | No | No | Low | N/A | None | |||||
Architectural Constraints and Considerations | Secondary Benefits | ||||||||||||||||
Both options were designed to support Panaroma's data model. | Using pan-Canadian terminology subsets supports inter-jurisdictional interoperability. SNOMED CT’s terminology model can be leveraged to support aggregation and analysis of the information captured within vaccination records | Use of CDA document allows content to be rendered in all other formats. Raw text based HL7 ORU and DICOM SR are widely used and present in DI-R systems and require support. | PDF may preclude secondary use, while the structured data of a CDA document supports machine readability and may enable secondary use of clinical data, clinical decision support or application of administrative/demographic data to analytics/business intelligence. | ||||||||||||||
Recommendation | Supporting Rationale | ||||||||||||||||
Clinical Document Architecture (CDA) R2 | It is | the goal of the Canadian XDS Affinity domain that reports will be stored in HL7 CDA format (using the pan-Canadian header format) as these reports (a) support required metadata, and (b) can be transformed to all other formats.||||||||||||||||
Anatomic Region Code
Metadata plays an important role in the identification of relevant priors during the fetch and pre-fetch use cases. The significant coded metadata elements for the FEM use case are the acquisition modality of image and the anatomical region being studied. Acquisition modality was adopted as prescribed.
recommended that new implementations adopt the custom reference value sets developed by Ontario. | The pan-Canadian Public Health Immunization Subsets reflect Canadian requirements (e.g. Canadian vaccine lists), and is aligned with the PHAC Canadian Immunization Guide. It is being adopted in additional projects across Canada (including AB, SK, MB, Canadian Forces, CIHI), so additional implementations that adopt the Ontario standard will be well positioned for interoperability with these groups or organizations. | |||||||
Single Sign On (SSO)
The following security frameworks were considered to provide SSO access to protected data through via FHIR resources.
Standard | Fit for Purpose | Stewardship | Quality | ||||||||||||||
Fits | Implementation | Vendor | Canadian | SDO | Complexity | Standard | Training, | ||||||||||
Coarse Body Parts (SNOMED CT subset) | Yes | Productionin Canada | HighNo | Yes | Localized | Medium | Normative | Good | |||||||||
Production | Anatomic Region (DICOM CID 4) | Limited | International | High | No | Yes | Medium | Normative | Unknown | ||||||||
Architectural Constraints and Considerations | Secondary Benefits | ||||||||||||||||
OAuth 2.0 provides better support for mobile applications. |
| Both terminology subsets referenced are published as flat lists with descriptions and codes. | Using pan-Canadian terminology subsets supports inter-jurisdictional interoperability. SNOMED CT’s terminology model can be leveraged to support aggregation and analysis of the information captured within vaccination records. | ||||||||||||||
Recommendation | Supporting Rationale | ||||||||||||||||
Coarse Body Parts (SNOMED CT subset) | The DICOM CID 4 value set is very detailed and generally inconsistent with the general approach of “casting a wide net” employed when fetching content within the FEM use cases. | ||||||||||||||||
Note:
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It is recommended that OAuth 2.0 be used to provide SSO access to protected data through FHIR resources. | Better support for mobile applications | |||||||
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