FHIR® – Fast Healthcare Interoperability Resources (hl7.org/fhir) – is a next generation standards framework created by HL7. FHIR combines the best features of HL7’s Version 2, Version 3 and CDA® product lines while leveraging the latest web standards and applying a tight focus on implementability.

Usability is the most important "ility."

The lack of usability of electronic health records (EHRs) and healthcare IT applications, in general, has been in the news again. A research report published in the Journal of the American Medical Association (JAMA) analyzed voluntary error reports associated with EHR systems and found that problems with EHR usability may have directly resulted in patient harm (Howe JL ; Adams KT ; Hettinger AZ; et al. Electronic health record usability issues and potential contribution to patient harm. JAMA. 2018; 319: 1276-1278).

Information Blocking and EHRs

You never know who you might be sitting next to!

Auto bumpers and HealthIT Interoperability

Ralph Nadar's book Unsafe At Any Speed raised public awareness of some of the safety problems associated with the Chevrolet Corvair.  Nadar’s book, however, was also an indictment of the auto industry as a whole and served as a lightning rod for legislation establishing what would eventually become the National Highway Transportation Safety Administration (NHTSA). 

These two industries, HealthIT and automobiles have quite a lot in common including that they are both highly regulated.  These regulations exist because in both industries poor design can lead to safety issues and the possible death of their user’s.

The FHIR Train Leaves the Station

by Ken Terry, iHealthBeat Contributing Reporter, iHealthBeat, Tuesday, May 26, 2015

Fast Healthcare Interoperability Resources (FHIR), a new standards framework from HL7, is starting to get traction in the industry as the latest focus of interoperability efforts. According to proponents of the rapidly evolving approach, FHIR promises to facilitate health information exchange, broaden the capabilities of electronic health records and accelerate innovation in mobile health applications.

In essence, FHIR uses snippets of data known as resources to represent clinical entities within EHRs. Certain application programming interfaces (APIs), otherwise known as plug-ins, can connect applications to FHIR-enabled EHRs without customized interfaces. A security standard known as OAuth gives patients the ability to access the EHR data themselves or grant access to providers and others.

FHIR has already gotten the attention of EHR vendors, some of whom are participating in the Argonaut Project. The coalition of 40-plus EHR suppliers, health care organizations and other stakeholders is implementing and testing the initial FHIR profiles. Among the EHR developers participating in the project are:

  • athenahealth;
  • Cerner;
  • Epic;
  • GE;
  • McKesson;
  • Meditech;
  • NextGen; and
  • Practice Fusion.

David McCallie, Jr., senior vice president of medical informatics for Cerner, said these vendors are expected to "go into production" on a subset of FHIR profiles within the next six to 12 months. "Hopefully, they'll all implement these core services for things like problems, medications and allergies," he said

EHR developers are taking notice of FHIR partly because the government might make it mandatory, McCallie noted. In the meaningful use Stage 3 proposal, CMS advocates for an "open API" that would allow patients to view, download and transmit their own EHR data. Although FHIR is not mentioned, the Office of the National Coordinator for Health IT cited FHIR several times in its 2015 EHR certification proposal.

The FHIR standard was recently coupled with another innovation designed by researchers at Harvard Medical School and Boston Children's Hospital -- the Substitutable Medical Applications and Reusable Technology platform. SMART provides a Web-based graphical user interface to FHIR, using software written in HTML5 and Javascript. The combined programming is known as SMART on FHIR.

An app developer could write an app to SMART on FHIR specs and would be able to connect it to any FHIR-enabled EHR. What this means is that consumers could select SMART on FHIR apps from outside firms and plug them into their provider's EHR.

Clearly, this would be an enormous spur to innovation among the nation's app developers.

Former U.S. CTO Aneesh Chopra said, "If you lower barriers to entry, you make it easier for innovators. A FHIR-enabled world should result in hundreds, if not thousands of apps, competing for the right to make better health decisions, live healthier lives and lower costs."

But this is the only the beginning of what SMART on FHIR might be able to do, according to Chopra and McCallie.

CCDA Replacement?

Currently, the only way to exchange care summaries between disparate EHRs is to use the CCDA, a document that follows another HL7 standard. But some EHRs are unable to exchange these care summaries because the standard is complex and allows too much room for variations. FHIR could provide a way to escape this dilemma by allowing discrete data to be exchanged directly instead of as part of a document.

The Argonaut Project is now focusing on a subset of FHIR that consists of the 16 data elements in the CCDA. Chopra said these components have been trimmed to 12 FHIR profiles. The Argonauts are testing these profiles and creating open-source implementation guides for them. "What FHIR proposes to do is to make it much easier to exchange and use the individual data elements," he said.

McCallie agreed. Noting how much simpler FHIR is than the CCDA, he said, "My bet is that a wider variety of vendors will be able to properly form FHIR messages than is currently the case with CCDA."

Another advantage of FHIR, McCallie said, is that clinicians can query other EHRs for just the information they're looking for, rather than having to obtain a CCDA and search the entire document for that piece of data. "With FHIR, you say, 'Just send me the patient's current conditions,' and you get it back in a second."

When a certified EHR sends a CCDA to another certified EHR, certain elements of the care summary are supposed to be transportable into the data fields of the receiving EHR. There's usually a "data reconciliation" step where the provider who wants to import some of the data looks it over first. Then he or she can bring the data into the correct field. "But not all vendors do this well, and it's slow," McCallie said. "It can take four to five minutes to do this, and doctors don't have four to five minutes.

"With FHIR, the doctor can say, 'Is my allergy record complete? Show me what else is known about allergies on this patient.' And they can do it in a couple of seconds, so doctors are more likely to do it that way," he said.

Expanding EHR Capabilities

EHR developers provide the core capabilities of EHRs and associated financial systems, "but we can't build everything that users need or want," McCallie said. "So the [FHIR-enabled] apps will open that up for extensions in ways that go beyond what the vendor had focus or interest or time to provide."

These apps might add new functionality to the EHR or they might enable EHR users to import additional data from other sources. For example, an accountable care organization might be able to provide a "population view" to a physician who participates in the ACO through a specialized app, McCallie said.

Another example of how this might work is being pioneered at Geisinger. Through its xG Health Solutions spinoff, the Danville, Pa.-based health care system plans to transfer the best practices it has developed for treating multiple health conditions to other health care organizations. xG will use apps to extract data from FHIR-enabled EHRs, analyze them, reorganize them and present the information back to the organization in its workflows.

If providers used FHIR-enabled apps to extend the functions of their EHRs, Chopra said they might create a marketplace for those apps. "Imagine a 1,000-doctor network that could choose among FHIR-enabled apps, and each specialty had different EHR extensions through apps," he said. "Only the ones that were used would be paid for."

Future of Interoperability

In the long run, Chopra said, FHIR could solve the technical problems of EHR interoperability. But business, legal and policy issues will continue to impede the flow of information, he predicted. The key to effective data sharing, in his view, will be the right of the patient to his or her own data.

"Whether the government forces hospital A to share data with hospital B or not, if they can both speak FHIR to the patient, the data become liquid and can be exchanged safely and securely through the patient," Chopra said.

McCallie questioned, however, whether consumers will be as interested in ferrying information between their providers as they are in using mobile health apps plugged into EHRs. Moreover, he noted that providers might be wary of importing such data into their EHRs because they don't know the information's source or whether it has been tampered with.

A more likely scenario, he said, is that providers in a region will form a cloud-based network that can share data through apps plugged into their EHRs. While this isn't very different from a health information exchange, he observed that HIEs have to work with vendors to write interfaces to all of the EHRs in their networks. "It's the difference between doing it the hard way with a lot of custom engineering or doing it with a plug-in that doesn't require any custom engineering."

With SMART on FHIR apps, it would be much easier to share information, McCallie said. "The app model should make it more uniform and less expensive."

Meanwhile, the FHIR train continues to chug onward, gaining adherents as it goes. EHR vendor Greenway is not part of the planning for SMART on FHIR, but Greenway CEO Tee Green praised the initiative.

Noting that Greenway has had its own API platform for four years, with 80 companies now contributing apps, Green said, "FHIR and other technologies continue that evolution. No longer will we operate in the Hotel California model, where you come but you can't leave. Those days are coming to an end. It's exciting, because consumers are demanding it, and it's going to create a tremendous amount of efficiency and technology breakthroughs."

Source: iHealthBeat, Tuesday, May 26, 2015