Thursday, September 6, 2018

PDQm using FHIR Subscription as Async API to XCPD/XCA

In the last article I covered the basic flow of using PDQm and MHD as an API to an XCPD/XCA environment. This is the classic intention of the current IHE Profiles.

But, the reality of XCA communities are that

  1. You likely have hundreds of communities to probe
  2. Some of those communities will be fast, some will be slow
  3. Some communities will be down and never respond

The reality is that the time between a Consumer asking a PDQm discovery request, and getting ALL of the results from ALL of the communities, might be many minutes. Yes, many minutes. That long of a time between a RESTful GET (query) and the response is unusual. A typical http RESTful api toolkit likely doesn't wait that long.

One solution is to just make sure all your Consumer implementations wait a very long time before giving up and assuming their Responder/InitiatingGateway infrastructure has failed them. How long to wait? This might be a value populated somewhere, like the CapabilityStatement on the Responder, or in a Service directory.

But that is not friendly to the user. You might be able to get the Consumer software to wait many minutes, but there is likely a human waiting that long too. It is possible to stream each result back as they become available, to the Consumer. I am not sure what that looks like. To stream the results would also require the design of the Consumer software to be expecting streamed results. Meaning it doesn't wait for the whole http response before it starts looking at what it does have... Again, not a friendly solution.

Lastly the Responder/InitiatingGateway must have a blocking thread for this many minutes too, taking up precious resources on the middleware.

Some of these problems are http RESTful, but most of them are general problems that exist even in the classic XCPD/XCA world using SOAP. 

FHIR has a solution ready to be used... Subscription.... With Subscription the Consumer creates a Subscription resource with the subscription criteria equal to the PDQm query it might otherwise do.  The Consumer gets notified as data matching that Subscription becomes available.

The typical use-case for Subscription is to register a subscription for new data that might appear in the future as created by someone else. In the use-case I am describing here it is as an Asynchronous mechanism for a set of transactions (XCPD). In my case the creation of the Subscription is a trigger to start some backend XCPD discovery. Once all of that XCPD discovery is done, then the Subscription is useless. So the end of the Subscription is different than typical use-case for Subscription.

I worked with a developer who implemented this as an internal API to their implementation that interfaces with the eHealth Exchange (Sequoia Network). Where there are well over 100 partners, and some partners take many minutes to respond. The result was a much more responsive application behavior, in that case a web-interface. In fact the whole response-time from start to complete finish was faster as the critical processing could happen during what would normally be wait time, rather than doing critical processing after all the network interactions happened. So double win!

This looks more busy, and it is.. but the waiting is between the gaps. The best part of this approach is that the "new results - ping 1234" will happen once for each Patient match found, and will happen when that match is available. Thus the Consumer software will learn of matches from fast partners really fast. The Consumer can then start doing something right then, like minimally displaying the results. Unlike the classic solution that prevents the Consumer from knowing anything until everything is known.

Note I used web-sockets here, which does require a the Consumer to query after each notification. There are other Subscription types that can pass the data back. I haven't experienced them, and don't see much written about them.

Here is the source for the UML diagram that can be used at

title PDQm Subscription -- XCA

participant Consumer
participant Responder
participant InitiatingGateway
participant RespondingGateway

note right of Consumer
based on some need a patient is of interest
end note over 
Consumer->+Responder: Create Subsubscription
note right of Consumer
Simply move the PDQm search on Patient 
into the Subscription criteria:
Subscription.criteria = Patient? blah = websockets
end note
Responder->Responder: check if valid request
Responder->InitiatingGateway: start discovery
activate InitiatingGateway
Responder->Consumer: Subscription Create success = 1234
Consumer->Responder: Open Web-Sockets channel
note right of Consumer
endpoint of Web-Sockets is identified 
in CapabilityStatement on Responder
uses websocket extension
end note
Consumer-->Responder: link this websocket to subscription -- bind 1234
Responder-->Consumer: successful link to subscription -- bound 1234

loop for --ALL-- Partners in Community
note right of InitiatingGateway
Design backend to be most responsive:
Could be thread pool, could be event driven 
Might use XCPD synchronous or asynchronous
end note
activate InitiatingGateway

InitiatingGateway->+RespondingGateway: XCPD Patient Discovery
RespondingGateway->-InitiatingGateway: found patient alpha @ beta community
InitiatingGateway-->Responder: store result in cache
activate Responder
deactivate InitiatingGateway
end loop

Responder-->Consumer: new results - ping 1234
deactivate Responder
activate Consumer
note right of Consumer
normal PDQm query
plus Consumer remembers the time it last queried
Find Patient?blah&_lastupdated=time
end note
Consumer->+Responder: PDQm Patient?blah&_lastupdated=time
Responder->-Consumer: results from Cache
note right of Responder
cached entries returned 
can be maintained or flushed
end note
deactivate Consumer
InitiatingGateway->Responder: notice all Partners have responded, or timeout
deactivate InitiatingGateway
note right of InitiatingGateway
Given no more can happen then done
end note 
Responder->Consumer: Close web-socket

Consumer->Responder: Update Subscription(1234) inactivae
deactivate Responder
note right of Consumer
at any time Consumer can inactivate
end note
note right of Responder
take down web-socket if still up
flush cache 
end note

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