The COVID-19 pandemic has served as an innovation catalyst for many healthcare delivery organizations. Within a short period of time, health systems had to find ways to perform tasks they previously did not execute, such as scheduling thousands of vaccination appointments online with people that are not regular patients and delivering healthcare visits between patients and doctors electronically.
Let’s pause for a moment and acknowledge what a great achievement this burst of innovation and implementation was in an industry that chronically underfunds IT and rolls-out projects over years, not months.
However, this accelerated innovation can also present a problem – there is no going back. Patients expect online services. Patients want to book appointments like they book services for their car or food delivery: online. Patients want the option to have phone or video visits instead of waiting weeks for face-to-face visits. There is a myriad of options for new applications that promise remote patient monitoring or improved diagnostics, workflows, etc. How can a CIO in Healthcare possibly cater to all the demands for innovation when they must shell out the majority of their budget to maintain a behemoth EHR Mega suite from one of the three main vendors in the U.S. at the same time?
Fortunately, there are interoperability standards that enable just this – connecting new applications that augment the functionality of core systems and let information flow between all of them. HL7 v2 was designed for this and has been around since the 1990s. It was developed along with other EDI standards, such as X11, in an age when files where exchanges in batches or real-time when a connection was available – in other words, before the Internet age. While HL7 v2 is focused on transacting clinical data, X11 was developed to transact claims.
Much has changed in the world since the 1990s, and HL7 v2 is still the reliable de-facto standard that our healthcare system and interoperability across providers runs on in 2021. But it is not a great standard in the age of web services and mobile applications. To ensure interoperability flourishes in today’s digital age, we now have HL7 FHIR (Fast Healthcare Interoperability Resources). Many of the new and promising applications that allow innovative functions and workflows are based on FHIR. The introduction of FHIR creates the following set of questions for a CIO at a healthcare delivery organization that is considering his or her innovation agenda:
The U.S. Department of Health and Human Services (HHS) announces that five cooperative agreements to health information exchange organizations (HIEs) to help support state and local public health agencies in their efforts to respond to public health emergencies, including disasters and pandemics such as COVID-19.
The HHS Office of the National Coordinator for Health Information Technology (ONC) is administering $2.5 million in funding from the Coronavirus Aid, Relief, and Economic Security Acts (CARES Act) signed by President Trump on March 27, 2020.
The funding will support local health information exchanges (HIEs) under the Strengthening the Technical Advancement and Readiness of Public Health Agencies via Health Information Exchange (STAR HIE) Program.
Each of the five recipients will work to improve HIE services so that public health agencies can better access, share, and use health information during public health emergencies. These efforts will also support communities that are disproportionately impacted by COVID-19.
“Health information exchanges have long served important roles in their states and regions by helping health data flow to treat patients,” said Don Rucker, MD, national coordinator for health information technology. “These STAR HIEs will help public health officials make real-time decisions during emergencies like fires, floods, and now, the COVID-19 pandemic.’
The five HIEs, each awarded two-year cooperative agreements, are:
Georgia Health Information Network, Inc. (GaHIN)
Georgia Health Information Network will support the Georgia Department of Public Health and Georgia Department of Community Health to better access, share, and use electronic health information, especially data from populations underserved and/or disproportionately affected by the COVID-19 pandemic. This will include increasing the reporting to a state-wide COVID-19 registry and expanding public health reporting and data enrichment for providers not connected to GaHIN.
Health Current (Arizona)
Health Current (Arizona) will support the Arizona Department of Health Services by improving the timeliness, accuracy, and completeness of hospital reporting of key COVID-19 healthcare data, including facility hospitalization metrics, personal protective equipment (PPE) inventories, and ventilator inventory and utilization. Health Current will also seek to reduce hospitals and health system burden related to state and federal reporting requirements by using the HIE as a data intermediary.
HealthShare Exchange of Southeastern Pennsylvania (HSX)
HealthShare Exchange will modernize the region’s pandemic response with the use of automated application programming interfaces (APIs), supporting the Philadelphia Department of Public Health and the Pennsylvania Department of Health. HSX will also facilitate public health agency use of the Delaware Valley COVID-19 Registry, and create new clinical data connections based on public health agency priorities.
Kansas Health Information Network, Inc. (KHIN) d/b/a KONZA
The Kansas Health Information Network’s KONZA team will expand the number of providers participating in the HIE, enhance lab data that is already being exchanged and combining it with existing HIE data for public health reporting, and add additional information to its real-time alerting platform for the Kansas Department of Health and Environment.
Texas Health Services Authority
The Texas Health Services Authority, in partnership with Healthcare Access San Antonio (HASA, a regional HIE covering multiple regions in Texas), a local hospital partner, and Audacious Inquiry (Ai), will conduct a proof-of-concept pilot to demonstrate real-time, automated exchange of hospital capacity and other situational awareness data through APIs using HL7 Fast Healthcare Interoperability Resources (FHIR). This improved reporting will support the Texas Department of State Health Services.
These five awards represent a range of activities across different geographic regions of the country. The cooperative agreements will include cross-recipient collaboration to leverage their collective expertise and ensure the sharing of implementation experience gained from the program. This will bolster the likelihood of success and enable better replicability of the projects throughout the country.
A new initiative launched by Health Level Seven International (HL7) seeks to use its widely recognized data exchange standards to help health care researchers more effectively acquire, exchange and use data in translational and clinical research.
The effort, called Vulcan, intends to use a model for collaboration among diverse stakeholders in the translational and clinical research community to define a common set of standards that can be implemented internationally, built on current agreements to use the HL7 Fast Healthcare Interoperability (FHIR) standard to facilitate data exchange.
“Improving data sharing can bring significant benefits to medical research, which is often a time-intensive and costly process that unnecessarily delays progress in discovering treatments for medical conditions because researchers are unable to share critical information,” said HL7 International CEO Charles Jaffe, M.D., Ph.D. “Project Vulcan aims to develop common solutions to help partners overcome these challenges.”
The initiative is the latest to use HL7’s FHIR Accelerator Program, which seeks to expand the FHIR standard and enhance market adoption through a programmatic approach that diverse stakeholders can use. The Accelerator Program aims to motivate and support market collaborations, seeking to speed the availability of FHIR to tackle important interoperability needs. Project Vulcan represents an ambitious new use of the FHIR Accelerator Program, pulling together a diverse multi-stakeholder group that includes government and regulatory agencies, standards development organizations, academic sites, technology vendors and patients.
With the advent of FHIR there is a clear path to utilize FHIR and other existing standards to execute the interoperable exchange of data for clinical research.
“Using FHIR to assist translational and clinical research is a natural extension for the standard,” said Rob Goodwin, co-chair of Vulcan and Vice President of Pfizer’s Global Product Development Operations Center of Excellence.
“Delivering a new therapy to market now takes 10 to 15 years at an average cost of $2.6 billion,” said Goodwin, who’s also on the TransCelerate Clinical Oversight Committee of TransCelerate BioPharma, a non-profit organization that works across the biopharmaceutical research and development community to improve the delivery of new medicines.
“The most powerful way to make research faster and less expensive is to bridge clinical care and clinical research, while keeping patient safety and compliance in mind,” said Amy (Nordo) Cramer, Vulcan co-chair and Pfizer Global Product Development Strategic Partnerships. Cramer continued, “Vulcan’s contributions in using FHIR to streamline data collection and submission, protocol representation, clinical trial setup and management, and for other data-intensive purposes will be a game changer for clinical research.”
Organizers of Vulcan are encouraging other entities to participate in the effort. More information about Vulcan and the project’s goals can be found on its website, www.hl7.org/vulcan.
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.
Health Level Seven International (HL7), announces the launch of the HL7 FHIR Accelerator Program. The program is based on a model piloted by the HL7 Argonaut Project and, more recently, the HL7 Da Vinci Project. The goal is to strengthen the FHIR (Fast Healthcare Interoperability Resources) standard and enhance market adoption through a programmatic approach available to myriad stakeholders.
Charles Jaffe, MD, PhD
“HL7 FHIR has achieved remarkable adoption on a global scale,” said Dr. Charles Jaffe, CEO of HL7. “An ever-growing community of implementers has emerged across a broad spectrum of health care, eager to participate in an agile onramp for FHIR adoption and implementation. The HL7 FHIR Accelerator Program provides the framework for that community to leverage the technical capability, management expertise and experience gained during the creation and growth of the Argonaut and Da Vinci Projects.”
Building on the success of current projects – Argonaut (provider-provider and provider-patient) and Da Vinci (payer-provider) – The CARIN Alliance has recently been approved as an HL7 FHIR accelerator project (payer-patient). The three projects are complementary initiatives.
“On behalf of the CARIN Alliance, its board and membership, we are grateful for the opportunity to work more closely with HL7 as part of the FHIR Accelerator Program as we work to develop additional FHIR implementation guides so consumers can get access to more of their health information,” said Ryan Howells, CARIN Alliance Project Manager and Principal at Leavitt Partners. “Consumers and their authorized caregivers are requesting more access to health care data with less friction to empower them to become more informed, shared decision-makers in the care they receive.”
The original concept behind accelerating HL7 FHIR began approximately four years ago with the advent of the Argonaut Project.
Health Level Seven(HL7) International, the global authority on interoperability of health information technology with members in 55 countries, announced election results for its board of directors at the 32nd Annual Plenary and Working Group Meeting in Baltimore, Maryland. The 2018 class of HL7 Fellows and the 2018 recipients of the W. Edward Hammond, Ph.D. volunteer of the year awards were also recognized at the event.
Incoming Board Chair
Walter Suarez, M.D., M.P.H., executive director, health IT strategy and policy, Kaiser Permanente, was selected by the membership to serve as the chair-elect in 2019 and as the board chair, 2020-2021.
HL7 Board Member Elections
Four members were elected to the HL7 board of directors for the 2019-2020 term:
Director — Kensaku Kawamoto, M.D., Ph.D., associate chief medical information officer, University of Utah Health Care
Director — Janet Marchibroda, fellow, Bipartisan Policy Center
AffiliateDirector — Diego Kaminker, owner, Kern-IT SRL and member, HL7 Argentina
2018 HL7 Fellows
The HL7 Fellow Award was presented to five individuals during HL7’s 32nd Annual Plenary and Working Group Meeting in Baltimore. The award was established to recognize HL7 members with at least 15 years of active membership as well as outstanding service, commitment and contributions to HL7. The 2018 recipients of the HL7 Fellowship Award include:
David Hay, M.D.
Beat Heggli
Patrick Lloyd
Rob McClure, M.D.
Corey Spears
HL7 Volunteers of the Year
HL7 honored three members with the 22nd annual W. Edward Hammond, Ph.D. Volunteer of the Year Award. Established in 1997, the award is named after Dr. Ed Hammond, one of HL7’s most active volunteers and a founding member as well as past board chair. The award recognizes individuals who have made significant contributions to HL7’s success. The 2018 recipients include:
Brett Marquard, principal, WaveOne Associates, Inc.
Ulrike Merrick, lead specialist, informatics terminology, APHL – Association of Public Health Laboratories and public health information specialist, Vernetzt, LLC
Bryn Rhodes, owner, Database Consulting Group and chief technology officer, HarmonIQ Health Systems Corporation
About the Volunteers:
Brett Marquard, has been a member of HL7 since 2008. Brett has held several positions throughout his 10-year tenure at the organization. For seven years, he co-chaired the HL7 Structured Documents Work Group. In addition, Marquard has served as the vice chair of the HL7 US Realm Steering Committee since 2016 and has chaired the newly established CDA Management Group since 2017. He is active in the effort to advance HL7 Fast Healthcare Interoperability Resources (FHIR®) and works with the ONC within the context of addressing their HL7 requests. Finally, Marquard been instrumental in the standards development process as the primary editor of the Consolidated CDA (C-CDA) and US FHIR Core implementation guides.
Ulrike Merrick, has been an active member of HL7 since 2008. She has served as a co-chair of the Orders and Observations Work Group since 2014 and was recently appointed to HL7’s newly established Version 2 Management Group. In addition, Merrick was elected to serve on the HL7 Technical Steering Committee beginning in January 2019 as the co-chair of the Administrative Steering Division. Much of her involvement in HL7 is focused on lab testing and reporting, and she has used her background in this area to engage the CDC in HL7 initiatives. Merrick has leveraged her broad network in the laboratory community to provide input from subject matter experts in relevant HL7 specifications, such as the HL7 Specimen Domain Analysis Model.
Bryn Rhodes, has participated in HL7 for several years and joined as a member in 2018. He serves as an interim co-chair of the Clinical Decision Support Work Group. Rhodes has also been involved in the efforts to extend HL7 FHIR into the clinical decision support and clinical quality measurement domains. He is the co-author of several HL7 specifications including the following: Clinical Quality Language (CQL), FHIRPath, FHIR Clinical Reasoning Module, QI Core/Quick and the CQL-based HQMF. In addition, Rhodes oversaw the transfer of the CMS electronic quality measure (eCQM) work using the CQL across multiple measure developers. Finally, he was instrumental in the Centers for Disease Control and Prevention (CDC) Adapting Clinical Guidelines for the Digital Age project’s incorporation of FHIR clinical reasoning and FHIR resources into the CDS L3 output and operationalizing the process by use in a CDC opioid management clinical guide.
Guest post by Justin Rockman, vice president of sales and business development, Surgimate.
Justin Rockman
Since the late ’80s, the inflexible and cumbersome Health Level 7 (HL7) protocol has been the standard form of sending messages between healthcare applications. However, HL7 integration is timely to implement, technically limited and costly. It is not uncommon for a medical practice to face upwards of $10,000 in expenditure for one simple message.
Application programming interfaces (APIs) have recently become a fashionable alternative. The term API sounds complicated, but it’s really just a way in which software applications (like your EHR) can talk to other systems, and exchange large amounts of data rapidly and securely. In short – they support better, faster, cheaper interoperability.
In addition to transmitting data between systems, APIs offer the ability to plug in chunks of functionality to another system, in a clean and predictable manner. Instantaneous and seamless interaction between systems is the leanest and trendiest way to design software in 2018. New applications should not “reinvent the functionality wheel” but provide unique integratable services.
As the EHR market estimated to reach $28 billion in 2016, it is no surprise that tech titans like Amazon, and Apple are looking for ways to get a slice of the pie. With top of the line products sure to come from those companies and others, here are 4 reasons why healthcare IT vendors must offer their clients a way to integrate using APIs.
Platform Stickiness
Physicians need easy access to data supported by EHRs, but hate the time it takes to manually enter patient information. It’s no wonder – doctors typically spend 50 percent of their day working with an EHR. If a physician isn’t happy with the usability or efficiency of their system, they’ll drop it and choose another. While the annual EHR adoption rate among providers is 67 percent, the EHR vendor switch rate is about 15 percent.
APIs offer cheaper and deeper integration options. For EHR vendors to provide better value for their customers they must embrace the API and ditch the expensive, outdated and rigid HL7 protocol.
Using an EHR that is integrated with other programs will make switching systems even more inconvenient. EHR vendors who give customers the additional functionality offered by their partners will be rewarded with brand loyalty, and lower churn.
An Additional Revenue Stream
Innovative EHR vendors are partnering with upstart technology companies to generate additional revenue. Greenway and athenahealth advertise an array of solutions in their marketplace, and provide partners with utilization of their APIs. In exchange, they receive monthly or recurring payment for each license sold. Since most practices already have purchased an EHR, finding new revenue streams is crucial for a company’s growth.
The healthcare API market is predicted to exceed $200 million in the next few years. Former engineers from Epic Systems saw the industry’s need for interoperability and raised $15 million in venture capital to found Redox – a company solely focussed on building bridges between healthcare applications. Creating platforms that deliver easy integrations at reasonable costs will greatly benefit the healthcare industry.
Last year, 2015, was a year of buildup, anticipation, and finally some bold moves to propel healthcare technologies forward, specifically regarding interoperability of data. The Office of the National Coordination, under the auspices of the department of Health and Human Services, released the long-awaited and much-debated meaningful use Stage 3 requirements in October. All the players in the health tech space were awaiting the final verdict on how Application Programming Interface (API) technology was placed into the regulations, and the wait was worth it, regardless of which side of the fence you were on. Before we get into the predictions, though, a little background knowledge about these technologies, and their benefits, will be helpful.
API Overview
An API is a programmatic method that allows for the exchange of data with an application. Modern APIs are typically web-based and usually take advantage of XML or JSON formats. If you are reading this article, you almost inevitably have used apps that exchange data using an API. For example, an application for your smartphone that collects data from your Facebook account will use an API to obtain this data. Weather apps on phones also utilize an API to collect data.
HL7 Overview
Next let’s take a look at the history of interoperability of healthcare data. HL7 2.x is a long standing method to exchange healthcare data in a transactional model. The system is based on TCP/IP principles and typically operates with Lower Layer Protocol (LLP) which allows for rapid communication of small delimited messages. The standard defines both the communications protocol and the message content format. No doubt about it, HL7 2.x is incredibly effective for transactional processing of data, but it has been limited in two key areas:
A pioneering developer of a successful HL7 interface engine once said: “Once you have developed one HL7 interface … you have developed one HL7 interface.” The standard exists, but there is nowhere near enough conformity to allow this to be plug-and-play. For example, a patient’s ethnicity is supposed to be in a specific location and there is a defined industry standard list of values (code set) to represent ethnicity. In reality, the ethnicity field is not always populated and if it is, it rarely follows the defined code set.
HL7 is an unsolicited push method, which means when a connection is made, messages simply flow from one system to another. If you are attempting to build a collection of cumulative data over time, this is a mostly sufficient method, but what you cannot do is ask a question and receive a response. Although some query/response methods have existed for years, their adoption has been very sparse in the industry.
2016: Year of the Healthcare API
If you are a physician with an electronic health record (EHR) system and you accept Medicare patients, you likely have gone through the process of becoming meaningful use (MU) certified, which means you have purchased an EHR software solution certified by the ONC. This EHR must follow guidelines of technical features, and physicians must ensure they utilize those features in some manner. In October 2015, the ONC released MU Stage 3 criteria (optional requirement in 2017, mandatory in 2018) which includes this game changer: A patient has a right to their electronic health information via an API.
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.
Health Level Seven
