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.
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 Department of Health and Human Services (HHS) filed its annual year-end report to Congress at the start of 2019. The 22-page report summarized nationwide trends in health information exchange in 2018, including the adoption of EHRs and other technologies that support electronic access to patient information. The most interesting takeaway has to do with the ever-elusive healthcare interoperability.
According to the report, HHS said it heard from stakeholders about several barriers to interoperable access to health information remain, including technical, financial, trust and business practice barriers. “These barriers impede the movement of health information to where it is needed across the care continuum,” the report said. “In addition, burden arising from quality reporting, documentation, administrative, and billing requirements that prescribe how health IT systems are designed also hamper the innovative usability of health IT.”
To better understand these barriers, HHS said it conducted multiple outreach efforts to engage the clinical community and health IT stakeholders to better understand these barriers. Based on these takeaways, HHS said it plans to support, through its policies, and that the health IT community as a whole can take to accelerate progress: Focus on improving interoperability and upgrading technical capabilities of health IT, so patients can securely access, aggregate, and move their health information using their smartphones (or other devices) and healthcare providers can easily send, receive, and analyze patient data; increase transparency in data sharing practices and strengthen technical capabilities of health IT so payers can access population-level clinical data to promote economic transparency and operational efficiency to lower the cost of care and administrative costs; and prioritize improving health IT and reducing documentation burden, time inefficiencies, and hassle for health care providers, so they can focus on their patients rather than their computers.
Additionally, HHS said it plans to leverage the 21st Century Cures Act to enhance innovation and promote access and use of electronic health information. The Cures Act includes provisions that can: promote the development and use of upgraded health IT capabilities; establish transparent expectations for data sharing, including through open application programming interfaces (APIs); and improve the health IT end user experience, including by reducing administrative burden.
“Patients, healthcare providers, and payers with appropriate access to health information can use modern computing solutions (e.g., machine learning and artificial intelligence) to benefit from the data,” HHS said in its report. “Improved interoperability can strengthen market competition, result in greater quality, safety and value for patients, payers, and the healthcare system generally, and enable patients, healthcare providers, and payers to experience the promised benefits of health IT.”
Interoperability barriers include:
Technical barriers: These limit interoperability through—for example—a lack of standards development, data quality, and patient and health care provider data matching. Addressing these technical barriers by coordinating to establish the technological foundation for standardizing electronic health information and by promoting exchange of that information can considerably remove these barriers.
Financial barriers: These relate to the costs of developing, implementing, and optimizing health IT to meet frequently changing requirements of health care programs. The cost to adjust health IT to meet these requirements can impact innovation and the timeliness of technical upgrades. Specific barriers include the lack of sufficient incentives for sharing information between health care providers, the need for enhanced business models for secondary uses of data, and the current business models for health systems or health care providers that do not adequately focus on improving data quality.
Trust barriers: Legal and business incentives to keep data from moving present challenges. Health information networks and their participants often treat individuals’ electronic health information as an asset that can be restricted to obtain or maintain competitive advantage.
Elsewhere, the Center for Medical Interoperability, located in Nashville, Tenn., is an organization that is working to promote plug-and-play interoperability. The center’s members include LifePoint Hospitals, Northwestern Memorial Healthcare, Hospital Corporation of America, Cedars-Sinai Health System, Hennepin Healthcare System, Ascension Health, Community Health Systems, Scripps Health, and UNC Health Care System.
Its mission is “to achieve plug-and-play interoperability by unifying healthcare organizations to compel change, building a lab to solve shared technical challenges, and pioneering innovative research and development.” The center stressed that the “lack of plug-and-play interoperability can compromise patient safety, impact care quality and outcomes, contribute to clinician fatigue and waste billions of dollars a year.”
More interoperability barriers identified
In a separate study, “Variation in Interoperability Among U.S. Non-federal Acute Care Hospitals in 2017,” showed additional difficulty integrating information into the EHR was the most common reason reported by hospitals for not using health information received electronically from sources outside their health system. Lack of timely information, unusable formats and difficulty finding specific, relevant information also made the list, according to the 2017 American Hospital Association (AHA) Annual Survey, Information Technology Supplement.
Among the explanations health systems provided for rarely or never using patient health information received electronically from providers or sources outside their health system:
Difficult to integrate information in EHR: 55 percent (percentage of hospitals citing this reason)
Information not always available when needed (e.g. timely): 47 percent
Information not presented in a useful format: 31 percent
Information that is specific and relevant is hard to find: 20 percent
Information available and integrated into the EHR but not part of clinicians’ workflow: 16 percent
Hospitals, when asked to explain their primary inability to send information though an electronic exchange, pointed to: Difficulty locating providers’ addresses. The combined reasons, ranked in order regardless of hospital classification (small, rural, CAH or national) include:
Difficult to find providers’ addresses
Exchange partners’ EHR system lacks capability to receive data
Exchange partners we would like to send data to do not have an EHR or other electronic system to receive data
Many recipients of care summaries report that the information is not useful
Cumbersome workflow to send the information from our EHR system
The complexity of state and federal privacy and security regulations makes it difficult for us to determine whether it is permissible to electronically exchange patient health information
Lack the technical capability to electronically send patient health information to outside providers or other sources
The report also details other barriers related to exchanging patient health information, citing the 2017 AHA survey:
Greater challenges exchanging data across different vendor platforms
Paying additional costs to exchange with organizations outside our system
[Need to] develop customized interfaces in order to electronically exchange health information
“Policies aimed at addressing these barriers will be particularly important for improving interoperable exchange in health care,” the report concluded. “The 2015 Edition of the health IT certification criteria includes updated technical requirements that allow for innovation to occur around application programming interfaces (APIs) and interoperability-focused standards such that data are accessible and can be more easily exchanged. The 21st Century Cures Act of 2016 further builds upon this work to improve data sharing by calling for the development of open APIs and a Trusted Exchange Framework and Common Agreement. These efforts, along with many others, should further improvements in interoperability.”
What healthcare leaders are saying about interoperability
While HHS said it conducted outreach efforts to engage health IT stakeholders to better understand these barriers, we did too. To further understand what’s currently going on with healthcare interoperability, read the following perspectives from some of the industry’s leaders. If there’s something more that you think must be done to improve healthcare interoperability, let us know:
“Consumer pressure is driving a disruptive technology-enabled shift in healthcare today,” said Hal Wolf, HIMSS president and CEO, in a statement about the report. “Digital health technologies are beginning to deliver on their promise to help providers understand individual consumer preferences and provide personalized care that effectively coordinates care throughout the broader health ecosystem. By fully realizing the potential of information and technology, we can create an ever-increasingly informed and empowered global community of innovators, care providers, and patients.”
Specifically, the HIMSS report addresses four key trends: digital health implications and applications, consumer impact, financial and demographic challenges, and issues of data governance and policy. “Digital health tools have been riding the peak of the hype cycle for several years now,” the report points out, “but 2019 will be the year that digital health will need to answer for the way technology will increase access to care and narrow gaps in care and coverage.”
Given these areas of focus, it’s a good bet that the upcoming HIMSS19 conference and trade show will heavily promote these ideals. Even with that, there are likely going to be many other takeaways from healthcare technology’s biggest annual event so we asked some industry insiders, experts and thought leaders what they hope become the main takeaways from the event once it has wrapped. Here’s what they said.
With every sector of the economy feeling the effects of ever-increasing healthcare costs and no relief in sight, it’s no wonder household names outside of traditional healthcare are stepping in and attempting to improve what could only be characterized as a problematic system.
Industry outsiders take an interest in “solving” healthcare
This year began with three modern-day titans of industry declaring they are ready to disrupt healthcare. Jeff Bezos of Amazon, Warren E. Buffett of Berkshire Hathaway, and Jamie Dimon of JP Morgan Chase announced they were forming an independent healthcare company for their employees. By June they named a CEO for this venture: Dr. Atul Gawande. A Harvard surgeon, author, and executive director for Ariadne Labs, Dr. Gawande has built his career on examining how medicine is practiced in the US.
Industry outsiders see data as a key leverage point
What is noticeably apparent with this surge in “healthcare outsiders” is that none of these big players are attempting to remake all of healthcare. To remake a system as vast and complex as the US healthcare system is more than any one company or consortium can reasonably hope to do.
However, they all do seem to be focused on data as the key point of leverage for disrupting and remaking a segment of healthcare. Gathering and processing data into diagnostic, predictive, or operational information is seen as the leverage point for ultimately making healthcare more efficient and effective.
Some of these industry outsiders are focusing their efforts directly on finding and exploiting opportunities for cost savings. Here are some examples.
Optimizing the pharmacy purchasing experience
Making the patient purchasing experience for pharmaceuticals, medical devices, and medical supplies seamless and reliable has drawn the attention of Amazon.
For the patient ordering and refilling prescriptions, the process could be automated and culminate in same-day delivery to the patient’s door. To some extent, patients will be able to comparison shop for non-prescription items and bundle purchases. For the seller inventories and distribution can be centralized and possibly some operational savings can be realized.
Finding a more efficient way of selling and delivering medical supplies will increase convenience for patients. But patients rarely pay the full cost of their prescriptions, so the cost drivers present in optimizing retail sales aren’t present at the pharmacy.