Few modern technologies have been quite as transformational as the internet. Pervading every facet of daily life, the information superhighway that society has come to know and love – and occasionally loathe – has enabled a level of communication, collaboration, insight, and analysis that has rendered the current generation of smartphone-addicted kindergarten coders unrecognizable to its forbearers.
But despite the healthcare industry’s recent efforts to become as tech-savvy as its peers in banking, retail, education, and manufacturing, the internet has remained relatively tangential to the medical profession.
The rapid proliferation of electronic health records, patient portals, and health information exchanges has done little to change how physicians make decisions and nurses care for patients – and many practitioners still believe that health IT tools do nothing other than get in the way.
For many providers, health data from their business partners is still a “nice to have” feature of systems that might never work as advertised. Emails from patients or business partners can be more of a nuisance than a time-saver. Mobile devices are consistently subject to a quagmire of security regulations that drastically restrict natural communication, and most web portals for quality reporting or regulatory programs look like they’re stuck in the dial-up days of 1992.
Healthcare has done little other than trade their paper charts and documents for digitized versions of the same old way of organizing, sharing, and presenting information – and that is why the industry has been unable to match the technological leaps and bounds of every other economic sector.
Luckily for the thousands of frustrated providers reaching their boiling point, the Fast Healthcare Interoperability Resource is starting to shine light on a better way forward for healthcare and its growing big data analytics needs.
Proponents of FHIR will be the first to say that it isn’t a new idea. In fact, it’s a fairly well-worn approach by now.
It’s just the internet, they shrug, but tailored to the complexity of healthcare big data in a way that document-based data exchange never could be.
FHIR can bring revolutionary change to healthcare simply by allowing the industry to catch up to the rest of the world’s familiarity and comfort with seamless, effortless data sharing.
What makes FHIR different than existing health data exchange methods?
The Fast Healthcare Interoperability Resource is a data standard that uses the same technology as the internet to enable the retrieval of health information. Instead of relying on document-based exchange – basically emailing pre-defined packets of static information back and forth between EHR systems – FHIR creates a unique identifier for every piece of information that anyone with a FHIR “browser” application can access.
Every data element, or resource, gets its own standardized, shareable identifier that acts like the URL of a webpage.
A resource can be an individual piece of information, such as a patient’s allergy list or lab result, or it can include multiple types of data bundled into clinical documents that mirror existing formats like the continuity of care document (CCD).
In the same way that they can access their favorite websites on the internet, any FHIR app user with access to the resource URL can engage with the information in certain ways, no matter what electronic health record “operating system” they are running on their device.
FHIR apps act like web browsers do when connecting with the individualized URLs. Just like Safari, Chrome, Firefox, or Internet Explorer, all of which work with different operating systems, a FHIR app allows users running different EHR platforms to connect to the same data in the same manner.
This approach eliminates the complex interoperability barriers rooted in proprietary data standards that have made it difficult to reliably scale up direct EHR-to-EHR data exchange.
“The shift is primarily around moving from the push model, in which everyone must already know their business partners in some capacity, to the pull model, which simply makes data available to you, and gives you flexibility as to when, where, why, and how you’re going to use it,” explained Shahid Shah, Entrepreneur-in-Residence at the AHIP Innovation Lab and CEO of Netspective Communications.
“Because it's built on the same technology that literally every other technology is now being built on, it’s very simple to use. We know it is the right approach because the foundations are good. And we know the foundations are good because the internet works.”
Still, the excitement over FHIR has been a little hard to fathom for end-users, who tend to care less about how an app functions under the covers and more about whether or not it actually makes their lives any easier.
And after years of slogging through the technical and workflow shortfalls of document-based health information exchange, it’s no wonder that FHIR developers still often encounter a world-weary skepticism when touting their wares.
“There have been a lot of other attempts that haven't quite delivered on their promises,” acknowledged Wayne Kubick, Chief Technology Officer at HL7 International, the organization that oversees development of FHIR. “People are very familiar with the Gartner hype cycle by now, and in some sense they’ve heard all of these promises before. That's the history of technology, and healthcare in particular.”
"We know it is the right approach because the foundations are good. And we know the foundations are good because the internet works.”
“The EHR transition has been very painful for most organizations. And people are always afraid of the pain. There's always a price to be paid with technology, and clinicians have been the ones paying it for a long time.”
But FHIR offers a true departure from the past, Kubick insists, largely due to the fact that it is taking its cues from architecture that has already clearly proven its benefits.
“It’s just not as painful as things we have tried before,” he said. “In fact, it's so flexible that it allows people to focus more on the user experience getting better and not just on the technology doing the fundamentals. That's part of the message we need to craft in order to get a broader acceptance of what FHIR can do for its users.”
“If we can give them something they haven't had before, and give them real access to clinical intelligence and actual insights, then we can focus more of our attention on smoothing out those other rough spots, like workflows and reporting requirements, which are causing so many problems.”
Using APIs to pull the industry past basic interoperability woes
Healthcare still has a long way to go before it can say it has solved interoperability, however. And despite what EHR users might be tempted to think, health IT developers are just as frustrated as their customers that data exchange barriers have been extremely difficult to eradicate.
“We’re the only industry still talking about interoperability, because everyone else has already moved beyond that. We’re the only ones still shipping documents back and forth. In every other industry, you just use an API,” said Jonathan Porter, Senior Vice President of Network Services at athenahealth.
“‘Hey, can I get your API?’ is a very common thing to hear in other sectors, but it’s just starting to become something we hear in healthcare.”
Application programming interfaces (APIs) have become a nearly-universal tool for building connections between unrelated datasets.
These standardized gateways to data assets allow developers to pull together multiple big data sources to generate a new service, like the way Expedia compiles flight times and prices from multiple airlines, or integrate access to existing data streams without building the entire resource from scratch, like embedding Google Maps into a retail chain’s location finder.
“We’re the only industry still talking about interoperability, because everyone else has already moved beyond that."
Because healthcare datasets are often very large, very complex, and are subject to a dizzying array of privacy and security rules, the API has opened up untold new possibilities to developers who had been unable to find their way into these hidden treasure troves of potential insights.
Coupled with the standardization and easier pull-based data access afforded by FHIR, appropriately permissioned APIs are building bridges between organizations that may never have interacted before.
“Under the traditional way of exchanging data, I had to wait until you had an event that met certain pre-defined parameters before you could give me any information,” explained Shah. “You had to be willing to give it to me, you had to know how to give it to me, and you had to initiate that transaction in some way on your end.”
“But even if you are the most wonderful institution in the world with all the resources imaginable at your disposal, just think about how complex that makes data sharing. You can't possibly think about every single interaction for every single patient that might possibly require a data push. You're not going to connect with thousands of people and have a team that somehow knows everyone in advance to push data out. It's just not possible.”
With a FHIR-based API, organizations would no longer have to initiate those interactions, such as admission, discharge, and transfer (ADT) alerts, every time a new event occurs.
Instead of requiring the treating hospital to send an ADT message through its EHR to a patient’s primary care provider – which means the treating hospital must know who that PCP is and how to contact her – the PCP could use an app that monitors the shared FHIR resources of high-risk patients and receive a notification in her EHR when the resource has changed to reflect a noteworthy event.
“The benefits of having access to data immediately like this aren’t just theoretical,” said Kubick. “They're very tangibly financial and clinical.”
“Data means your patients aren't going to the hospital if they don't have to. It means alerting them to particular risks and dangers that will change how they approach their lives. There are significant economic advantages to this, in addition to be basic net-good of keeping people healthier in their daily lives. How can you say no to that?”
Fanning the flames in the vendor and development communities
Yet perhaps due to those still-fresh wounds of EHR adoption, healthcare organizations have been somewhat hesitant about diving into an entirely different way to conduct the core of their business, said FHIR evangelist Dr. Viet Nguyen, who previously served as Chief Medical Officer at Leidos and now works as an independent consultant.
In some sense, the FHIR and API environments rely on building a critical mass of participants before it can become an effective way to share big data, and no one wants to be first to dip their toes in new waters when privacy, security, revenue, and reputation are on the line.
“A year or two ago, when I asked CIOs what it would take for them to adopt FHIR, the answer was always the same: when somebody else does,” Nguyen said.
“But that has changed quickly as some of the pioneering providers have worked through their pilots and test cases successfully. Now, we can point to organizations like Intermountain Healthcare, University of Utah, Duke, and Boston Children’s. These are leading organizations that have adopted FHIR, are putting it into production, and are sharing their use cases with their peers.”
Most of the major EHR vendors are getting into the spirit as well, he added.
“Many of the big EHR names have publicly expressed their plans to make APIs available to all their customers within the next year or two, which is huge. The EHR vendors are providing test beds for application developers, which is wonderful.”
Epic Systems, Cerner, Allscripts, athenahealth, and more have all openly committed to FHIR and APIs as the technologies of the future, complementing their various pacts, pledges, and coalitions focused on bringing interoperability to their customers as quickly and efficiently as possible.
“The vendors have simply decided that they must support it,” said Porter. “FHIR has become a minimum bar in the healthcare industry that everyone has to cross. That is a positive step, because it levels the playing field and creates a shared vision of what we have to do in order to work together.”
“It’s great for us at athenahealth, and for the people at Epic and Cerner and everywhere else as well, to have a set of APIs that mean something to all of us,” he added. “It will be wonderful for the entrepreneurs out there, because if we all interface with a FHIR API, they don’t have to duplicate the same work for every vendor they want to connect to.”
"When I asked CIOs what it would take for them to adopt FHIR, the answer was always the same: when somebody else does.”
Getting the vendor community engaged in the development and deployment of FHIR is a critical win for the data standard, but it’s only the first step, cautioned Nguyen.
“We’ve done a fairly good job of educating people about what FHIR can do,” he said. “Now we have to educate people about what FHIR is doing.”
“So many of the leading providers are doing very creative things with FHIR. As organizations start to make investments and develop plug-and-play tools for their specific high priority use cases, they will filter down to smaller organizations one way or another – and that’s where adoption is really going to take off in the broader healthcare community.”
Opening up the development landscape to new ideas
FHIR also drastically lowers the bar to entry for applications developers, Shah said, since they no longer need to have an intimate knowledge of healthcare-specific programming languages.
Because FHIR is built on the same underlying technologies as the rest of the internet, it functions similarly to other tools they may have encountered before.
“You don’t have to go learn HL7 anymore,” he said. “Now you can just hook up the API to a clinical data repository the same way you would hook up an API to Amazon or Google or Facebook.”
“Now we can leave it up to individual developers to decide that maybe there's value in the data coming out of Apple HealthKit for diabetic management, or predicting heart problems, or whatever the use case may be.”
“There's a 22-year-old fresh out of college somewhere who's got big ideas about how to streamline the patient experience or a clinical workflow, and FHIR lets her take her ideas and run with them in a way that was never possible before.”
FHIR increases the ease with which developers can jump into the lucrative healthcare app development landscape, Kubick added, allowing innovation and experimentation to thrive.
“One of the great things about FHIR is that it allows small players to compete effectively with large players. Of course, the market will level off and crystalize around the people who are most successful, but FHIR promotes the entrepreneurial experience that will bring new ideas into play.”
“The market is a good judge of what’s worth keeping around. And while it is very important to make sure that these apps meet clinical standards, HIPAA regulations, and everything else, we might find that some of the best new ideas come from someone who doesn’t have a strong background in medicine.”
“They might come from someone who has simply thought of a better way to interact with the healthcare system. And because FHIR is easy to work with, they will have a chance to bring their ideas to market the same as anyone else.”
“There's a 22-year-old fresh out of college somewhere who's got big ideas about how to streamline the patient experience."
Transferable skills have historically been rare in healthcare, leading to a worrying shortage of data scientists and health IT developers who can meet the exacting demands of an insular industry – and an entire generation of specialists who are the only ones who hold the secrets of aging legacy systems.
“Those coders are getting to the age where they’re thinking about retiring right now,” Shah pointed out. “And when they do, they’re going to be leaving organizations without the specialized skills they need to extract the clinical intelligence required to do business.”
“FHIR generally requires you to connect to something on the backend, so now is the time to learn how to get access to that data before you lose the people who know how to make that happen. Before we can get to the point where we can easily swap developers with other industries, we need to invest in smart people who can bridge HL7 to FHIR.”
FHIR represents a “radical change” for the healthcare industry in more ways than one, said Kubick, and it hasn’t been easy to get the wheels turning – especially in the midst of significant financial and regulatory overhauls that can divert attention and resources away from innovation.
“The key will be to get healthcare organizations to take the steps that will actually put these tools in place,” he said.
“It doesn't necessarily help that the political environment is so uncertain, because it adds another problem that people will want to solve before they start speeding into more development. But the resistance isn’t because they don’t believe FHIR works. It’s more a matter of business circumstances that need to be resolved, and that will happen in time.”
As healthcare gets more comfortable with moving through an app development process that mirrors other industries, the pressures should ease, the caution should subside, and the adoption rate should speed up, Nguyen agreed.
“FHIR is starting to let us develop knowledge bases that are reusable for multiple applications, and that is going to drastically cut the adoption burden, especially for organizations that aren’t necessarily on the leading edge of health IT.”
“The smaller hospitals and organizations that want these tools, but can’t necessarily develop them on their own, will be able to benefit from the collaborative community that FHIR really encourages. We just need time to mature the way we work through those cycles, and I believe we are well on our way to doing that.”