Skip to main content

Your Hospital on FHIR


As a technologist, I am always skeptical when hearing about a brand new technology that is going to solve all of our current problems. I feel it is my responsibility to warn people about these types of promises.
Claims of “solving all healthcare information exchange (HIE) problems” are often being made about the emerging HL7 FHIR standard. According to Gartner’s hype cycle, the standard is at the “Peak of Inflated Expectations,” which I view as a stage where wishful thinking fills the gap created by a lack of knowledge and understanding.
FHIR, which stands for Fast Healthcare Interoperability Resources, is a draft standard from HL7 International. This standard is designed to be easier to implement, more open and more extensible than its predecessors, V2 and V3 standards.
So what’s the big deal here? Aren’t we simply replacing one transport protocol with another?
FHIR claims to bring a change in paradigm to the way health information can be accessed and consumed. Since FHIR is a RESTfull API, it allows access to the source of truth on demand and in real time. This capability has many advantages over the message-based, push-and-deliver model of other HL7 protocols.
Applications that build on FHIR do not have to copy and sync data from one system to another, a process that is often cumbersome and lengthy. There is no risk of data being stale, which is crucial in many clinical scenarios. Bi-directional communication, which was always a hassle in previous versions, is an integral part of FHIR. The fact that FHIR is an open standard (all documentation can be found on the web) and leverages modern web-based technologies such as HTTP/S, JSON, OAuth for authorization and ATOM for query results, means that most developers can adopt it easily.
Talk of FHIR includes all the right buzz words, but like any standard, it is just a tool, and the success of the tool depends on its adoption. So far, the adoption of FHIR has been quite remarkable. Although the current 3.x release is still defined as a “Trial Use Specification,” and only Release 4 is slated to include content that will be considered stable and ‘locked’, many of EHR vendors like Epic, Cerner, Meditech, eCW and iMDsoft announced their support for the standard. FHIR-based solutions have been piloted in many mobile health, pharma, precision medicine and public health sectors.
FHIR, however, faces the same challenges as the popular V2 messaging protocol: inconsistent implementations, multiple sub versions, and partial adoption by the community.
The FHIR standard is very broad and includes over 100 resources which are considered the core elements of healthcare. It covers not only clinical data but billing and payments as well. The patient resource, for example, supports animals and species. This wide coverage becomes a disadvantage when companies want to achieve complete adherence to the standard.
In order to mitigate these challenges, FHIR profiles, which are subsets of the standard with extended definitions, are being created. One particularly important profile is the Argonaut Project, which is a joint project of major US EHR vendors and hospitals such as Beth Israel Deaconess Medical Center and the Mayo Clinic. The INTEROpen group also provides clinical validation of FHIR profiles for use in the NHS and social care.
So what will the future HIE look like if everyone makes the switch to FHIR? What practical solutions will be available to care delivery organizations (CDO) in this new world that will truly make a difference?
In my opinion, the main benefit of FHIR is the ability to tap into a clinical repository on demand and interact with it. This capability brings interesting opportunities for mobile apps and other “add-on” products that can complement an enterprise EHR and that are sorely missing in today’s world. CDOs are looking to extract more value out of their expensive IT investments. FHIR has the potential to create an ecosystem of value-added products that EHR vendors are not willing or do not know how to provide. Startups and small companies are struggling to penetrate the market due to the complex and often costly integration work required.
On that note, it is important to mention the “SMART on FHIR” project sponsored by Boston Children’s Hospital. SMART, which stands for “Substitutable Medical Applications, Reusable Technologies”, is an open-source standard designed to enable “plug-in apps” to run natively inside any compliant EHR. SMART builds on FHIR and adds the necessary elements, such as context sharing and security, for developing clinical apps. In the SMART gallery there are already 41 apps, like nomogram and score calculators, that can supplement the capabilities of an enterprise EHR.
The issue of interoperability was solved in industries such as banking, airlines, and tele-communication, but we have yet to find a satisfactory answer for healthcare. Interoperability tears down the walls and allows innovation to flourish. FHIR meets the healthcare IT industry at a fortuitous moment. CDOs are starting to evaluate new technologies beyond what is provided by their EHR, such as predictive algorithms, machine learning, mobile access from any device, new decision-support methods, and real-time surveillance tools. Like PCs or smartphones, EHRs can become the platform for running all kinds of interoperable products, and the value of that interoperable ecosystem can surpass the value provided by the core platform.
FHIR still has a long way to go and many hurdles to overcome if it is to meet the high expectations of the HCIT community and fulfill the promise of seamless integration. At this point, I can only speculate about whether seamless integration will become a reality and when. If it does, however, I feel confident that FHIR will play an important role in that new world.

Comments

Popular posts from this blog

FHIR Status Check

 More than 2 years have past since I wrote my article  on the Fast Healthcare Interoperability Resources (FHIR®) standard and it’s time to do a quick status check and revisit the predictions I made back then. The FHIR standard continues the strong trajectory of adoption and is now used across the globe. The application programming interface (i.e. the FHIR API) is available in most major EHR systems today. According to the US Office of the National Coordinator Health Information Technology an estimated 85% of hospitals have FHIR in their systems. The NHS has been quick to adopt FHIR and the adoption curve in the UK is high. The NPfIT (NHS Care Record Service) HL7 V3 interfaces are being redeveloped in FHIR®, and new NHS specifications such as the CareConnect standard for secured Transfer of Care  are being specified in FHIR® by default. Despite the industry enthusiasm about the potential of FHIR still the old and faithful HL7 v2 remains the predominant interoperability standard in use t

Home grown and die slow systems

The atmosphere got tensed as the meeting went on. We were all started feeling a bit uncomfortable. The meeting took place at headquarters of one of the prestige hospitals in the US. A hospital which constantly ranked in the top 10 best hospitals in the world. A drop of sweat sprout on the brow of the IT executive which was leading the meeting. The participants nodded their heads as they realized that despite the massive investments in developing their home grown systems over the years they are lacking some basic features which typically found in commercially available products, and many of the modules in used are becoming old and need to be replaced. That same realization repeated itself in similar discussions I had with other health organizations around the globe which took the "home grown" path. It seems there was a paradox between how wealthy is the organization and how poor its IT systems are. Selecting a commercially available product is a frustrating task. Typic

Hospital CXO - A new well deserve seat at the executive table

I once asked the CEO of a large hospital what will be the main KPI to measure how well the hospital is doing. The CEO immediate response was that the best indicator would be how satisfy the patients are. In a stressful and overloaded environment such as a hospital, it is easy to focus on the disease and forget about the patient. A chief experience officers (CXO), or other similar titled leaders, is a new member in a hospital C-suite. The role of a CXOs have gained scope and respect in the C-suite as studies show how experience affects all aspects of care. There is a growing body of evidence supporting that the association between better patient experience and health care quality. For example, a study found that a higher CMS star rating was associated with lower patient mortality and readmission's.  One of the drivers accelerating the adoption was the US government decision to start mandate measuring patient’s perception of their care and tied reimbursement to those scores. Beyond t