Electronic Health Reporter

By Scott E. Rupp, publisher, Electronic Health Reporter.

The healthcare technology world is ablaze, on FHIR. New proposed standards for interoperability are being established to allow health systems the ability to share information and facilitate patient access to data. Specifically, in large part through a structure known as FHIR.

This “FHIR” the market is speaking of is Fast Healthcare Interoperability Resources, an interoperability standard for electronic exchange of healthcare information. FHIR was developed by Health Level Seven International (HL7), a not-for-profit that develops and provides frameworks and standards for the sharing, integration and retrieval of clinical health data and other electronic health information.

FHIR emerged in 2014 as a draft standard for trial use to enable health IT developers to more quickly and easily build applications for EHRs and to exchange and retrieve data faster from applications. FHIR soon received support from EHR vendors like Epic, Cerner and AthenaHealth. Shortly thereafter, the Argonaut Project emerged to move FHIR forward, and in February 2017, FHIR became a full data exchange standard.

FHIR is interoperability

FHIR is built on the concept of interoperability and modular components that can be assembled into working systems to try to resolve clinical, administrative and infrastructural problems in healthcare.

FHIR provides software development resources and tools for administrative concepts, such as patients, providers, organizations and devices, as well as a variety of clinical concepts including problems, medications, diagnostics, care plans and financial issues, among others. FHIR is designed specifically for the web and provides resources and foundations based on XML, JSON, HTTP, Atom and OAuth structures.

FHIR can be used in mobile phone applications, cloud communications, EHR-based data sharing and among institutional healthcare providers.

According to HL7, FHIR aims to simplify implementation without sacrificing information integrity. FHIR “leverages existing logical and theoretical models to provide a consistent, easy to implement and rigorous mechanism for exchanging data between healthcare applications. FHIR has built-in mechanisms for traceability to the HL7 RIM and other important content models. This ensures alignment to HL7’s previously defined patterns and best practices without requiring the implementer to have intimate knowledge of the RIM or any HL7 v3 derivations.”

Health sector buy-in

The healthcare sector has clearly bought into FHIR, primarily because of interoperability challenges.

“Sharing data between different health systems has required significant investment of IT resources on one-off projects,” said Nilesh Chandra, healthcare expert at PA Consulting. “As the needs for data sharing have increased, hospital IT departments have been swamped with demand for all of this custom integration.

“FHIR and similar standards are an attempt at standardizing data integration, to make it easier to connect EHR systems and easily extract or upload data into them, based on reusable IT components,” added Chandra. “That said, FHIR is an important step in the right direction, but is not the panacea for all health IT integration issues.”

FHIR uses a set of commonly used medical ideas termed as “resources.” The resources are used across many different types of companies and organizations, but can all mean the same thing. An example would be blood pressure readings, or an MRI scan. Those resources are held in EHRs, smartphones, health information exchange databases and so on. FHIR also allows for the mining of those elements since they are tagged in a similar way in the FHIR standard.

“The complex part is done by individual systems that don’t have the same operating system,” said Jason Reed, PharmD blog founder. “Because they can pull that tag then they pull it and exchange it with other entities. They only show the tag and not the other code or structures they had to use to get to that tag.”

While consolidated clinical document architecture allows a group of healthcare items to be sent together, this is essentially like sending an electronic PDF, Reed said. Other systems that have different operating systems can’t break that down unless they use the same operating system.

FHIR’s culmination

All of this is a culmination of the fact that digital health data can improve outcomes and lower costs, but the reality has been something less than ideal. For example, during the economic stimulus in 2009, systems were designed before modern web standards for storing and exchanging data were ubiquitous. The industry was caught in the middle of a technical revolution and spent its cash before the best new practices were available, said Nick Hatt, senior developer at Redox.

The result was overwhelming frustration from developers attempting to build software to exchange the newly digitized health data.

“Over the past few years, a new hope has arisen. The standards body HL7 has been working to create a new version of a healthcare standard that promises to make healthcare data exchange work ‘like every other industry’ and allow the promise of digital health records to be realized,” Hatt said. “That is the FHIR standard. FHIR presents a common standards framework and is our best attempt to modernize healthcare data exchange. With a strong foundation in web standards, support for RESTful data exchange and an emphasis on human readability, FHIR is an attempt to make interacting with healthcare data more accessible to developers.”

The current version of FHIR takes lessons learned from the creation and implementation of HL7v2, HL7v3 and clinical document architecture standards, and attempts to address known problems while introducing new best practices. However, the adoption of HL7 standards, historically, has been primarily driven by EHR vendors. These vendors must first implement the standard in their own software and then deploy to healthcare organizations, though.

Ideally, FHIR is a quick win for integration; it’s a standard and everyone knows the standard — essentially it is an easy box to check for integrations, said Chris Yager, vice president of technology at MyHealthDirect. “Basically, FHIR allows you to very quickly determine if you can integrate and do what you need to do. As adoption increases the cost of integrating with disparate health systems will decrease. Good for patients, providers, lowering the cost of health IT in general.”

In January 2019, FHIRv4 was released, another attempt at getting the healthcare community closer to true interoperability. But each EHR vendor supports a specific subset (and not necessarily the same subset) of older releases rather than the entire specification, Hatt said. This raises concern that FHIR will be susceptible to many of the same interoperability issues witnessed with standards like HL7v2 or CDA in which standards are inconsistently adopted or implemented and interoperability issues run rampant.

According to Florian Quarre, chief digital officer at Ciox, FHIR aims at saving time, improving accuracy, increasing patient safety and standardizing security to support care delivery and research. An extension of HL7’s earlier data formatting standards, FHIR is built for the modern digital landscape and operates across siloed health care environments. This means easier, more fluid exchanges of data for providers and payers, and better decisions and outcomes for patients.

As of this writing, more than 85 percent of hospitals are using products certified on FHIR Release 2, said Ken Perez, vice president of healthcare policy at Omnicell. Likewise, ONC bolstered its support of FHIR in February 2019 when it issued a proposed rule making FHIR a standard to which third-party developers must certify their application programming interfaces.

Jeff Sponaugle, chief technology officer at Surescripts, said FHIR shoots for the 80 percent of use cases instead of trying to cover 100 percent of uses cases. The FHIR standard is available not just as an open specification, but as a set of open-source libraries available for download by anyone, which reduces the cost of entry into this ecosystem.

“Sharing clinical data is part of the simple goal of giving clinicians all of the data they need to make better decisions,” Sponaugle said.

Interoperability is a critical component of success in today’s healthcare ecosystem; it’s the cornerstone of a patient-first perspective, Corinne Proctor Boudreau, senior solutions manager for physician experience at MEDITECH said. “Use cases are what are pushing standards-based interoperability forward, the need to share information across locations and care settings for higher-quality patient care, better outcomes, and clinical efficiency which result in provider and patient satisfaction.”

Backing that goal, the ONC has been a strong supporter of the FHIR standard, going as far as releasing “Inferno,” which is a FHIR-based testing suite that helps people implementing FHIR in a testable way.

ONC has stated that FHIR is one of the important tools in the toolbox needed to meet the interoperability goals in the 21st Century Cures Act (Cures Act). ONC’s current proposed rules include requiring support for FHIR.

Given this and the industry’s move around the “campFHIR,” the standard continues to show great potential for staying hot.