Only a few short years after the Fast Healthcare Interoperability Resources were introduced to the healthcare industry, almost no one knows what they are.
The lengthy, somewhat cumbersome proper name has nearly disappeared from print, and is rarely to be found in online articles, vendor marketing materials, or even technical implementation guidance.
No one needs to know what the Fast Healthcare Interoperability Resources are anymore, because the moniker has been replaced by a curiously catchy acronym – one that is short enough, concise enough, and memorable enough to withstand the remarkably heavy use it is getting across all segments of the healthcare ecosystem.
FHIR is everywhere.
From major technology vendors to federal agencies to some of the most well-known providers in the country, nearly everyone with a stake in the world of healthcare data seems to have agreed that FHIR’s internet-based approach to sharing and exchanging information offers the most tangible promise for achieving the industry’s goals of seamless interoperability and patient-centered, data-driven care.
FHIR has moved from pie-in-the-sky to boots-on-the-ground at a scorching pace, said Charles Jaffe, MD, PhD, CEO of HL7 International, the organization in charge of nurturing FHIR and other healthcare data standards.
“FHIR is no longer part of the hype around creating more seamless access to data that can enable much more patient centered care,” he told HealthITAnalytics.com at the HL7 FHIR Applications Roundtable held in late September of 2018.
“It’s now part of the promise of a better environment for patients and providers – an environment we are well on our way to creating. You don’t need to explain what it is anymore – or at least not as much as you used to. You certainly don’t need anything other than the acronym. We’ve moved extremely quickly through that educational phase, and that is very encouraging to see.”
2018 has been a big year for the standard, Jaffe said, and 2019 is shaping up to be even more exciting for developers and providers eager to deploy the tools they need to take the next steps towards value-based care.
And while HL7’s periodic events give the industry a chance to reflect on its successes and showcase its achievements, they also serve as a launch pad for the next phases of the rapidly evolving community that has been drawn to FHIR like moths to a flame.
This year, as technologists, strategists, start-ups, and a few industry veterans converged on Washington, D.C., there was a sense of inevitability and momentum alongside the visionary excitement: FHIR has arrived, and now the industry is cooking with gas.
The blistering pace of FHIR-enabled interoperability
The industry’s commitment to the standard has been surprisingly swift and decisive, especially in light of the seemingly endless squabbling over interoperability and proprietary architecture that has simmered since the early years of the decade.
“We have really hit a turning point this year,” said Jaffe. “FHIR has been progressing steadily for quite a while, but there have been three very important moments in the private sector that have really cemented FHIR into the technical consciousness.”
“One, of course, was Apple’s announcement of the inclusion of FHIR in the iPhone iOS. Not as an app – it’s in the operating system itself,” he stressed.
“That really set the stage for the success of the Apple Health Records option. They had initially invited twelve university health systems to participate. It quickly became five hundred, and now they can’t line them up fast enough, because everyone wants to participate.”
The second was the launch of the payer-focused Da Vinci Project, he continued. A companion to the provider-centered Argonaut initiative, Da Vinci began in late January of 2018 with participation from some of the industry’s heaviest hitters.
In addition to Allscripts, Cerner, Optum, and Epic on the technology side, Da Vinci involves most of the country’s biggest commercial payers: Anthem, the BlueCross BlueShield Association, Humana, and UnitedHealthcare.
“The insurance companies basically said that they can’t continue to use claims data as the only real source for their analytics if they’re going to support care that’s based on outcomes and not on services,” Jaffe explained. “When they agreed to sit at the table and put aside their competitive issues, it started to change the entire industry’s thinking.”
The third pivotal event was an announcement from another powerful corner of the industry. In August, Amazon, Google, Microsoft, Salesforce, IBM, and Oracle, signed a joint pledge to accelerate interoperability across healthcare by leveraging cloud-based technologies and data standards in pursuit of the common good.
FHIR will be central to that mission, Jaffe confirmed.
“I followed up with quite a number of the companies participating in the announcement,” he said. “In many instances, they have already begun to implement their plans and actually start sharing cloud-based health data using FHIR.”
“When they agreed to sit at the table and put aside their competitive issues, it started to change the entire industry’s thinking.”
These companies, all of which are jostling for market share as healthcare organizations continue their migration to the cloud, represent hundreds of millions of dollars in investment, Jaffe noted.
“They’re pouring money into this technology because it works,” he said. “The private sector knows it. There isn’t a federal agency involved in healthcare that isn’t now interested in adopting FHIR. Pretty much everyone who has a hand in healthcare is on board, so it’s no surprise that these companies are going to be committing to it, too.”
All of this activity is taking place as a critical regulatory deadline inches closer, explained Micky Tripathi, President and CEO of the Massachusetts eHealth Collaborative (MAeHC) and a leader of the Argonaut Project, a private sector initiative that has taken on much of the heavy lifting of developing the FHIR standards themselves.
“In January of 2019, the requirement to be using 2015 Edition Certified EHR Technology (CEHRT) comes into effect,” he said.
A 2015 Edition electronic health record is required for attestation to the Merit-Based Incentive Programs for eligible physicians and the Promoting Interoperability program, formerly known as meaningful use, for hospitals.
One of the most talked-about components of 2015 Edition CEHRT is the ability to allow patient access to personal health data through an application programming interface (API) without requiring ‘special effort’ to access and use.
While there is currently no technical requirement to use one method over another for enabling this consumer-facing API capability, FHIR is the standard of choice for EHR vendors serving close to 80 percent of the hospital and physician group landscape, according to a recent ONC analysis.
“It’s a major measure of success that so many vendors have chosen to use FHIR for this even without a directive from the regulatory community,” observed Tripathi. “And the speed with which that happened is truly a little mind-boggling.”
“It’s easy to forget that the Argonaut Project actually started not that long ago, at the very beginning of 2015. Now, less than four years later, it’s reached 80 percent of providers and Apple has baked it into its operating system.”
“Anyone who thinks this stuff is happening too slowly…I don’t know how much faster you think this can happen. That’s pretty darn fast.”
Spreading enthusiasm while containing variability in implementation
But speed, coupled with a lack of firm regulatory direction, can bring challenges. FHIR may be a standard, but it doesn’t have a single on/off switch.
Developers creating apps or integrating FHIR-based connections into existing software must make a series of implementation decisions that can lead each iteration down branching paths.
“The Argonaut Project did a lot of work at the beginning to define a constrained set of FHIR resources so that they can be implemented consistently,” said Steven Posnack, MS, MHS, Director of the Office of Standards and Technology at the Office of the National Coordinator.
“Once you get beyond that core set, however, you have to start making decisions about how to implement certain things, and that’s where variation starts to creep in.”
“We need to make sure that developers are employing those consistently as FHIR starts really moving into the market. Consistent use and deployment of the specification in the real world will be key to creating an overall positive experience with FHIR.”
At the moment, that consistency is somewhat lacking, noted Tripathi.
“Right now, every vendor is doing its own thing in terms of FHIR,” he said. “The consumer-facing API is the common denominator, but beyond that, everyone has their own strategy.”
“So if you’re an app developer, you can’t count on much beyond that consumer-facing API. You have to go talk to Epic, and talk to Cerner, and talk to MEDITECH about what each one of them is doing before you can create something that is broadly applicable across the board.”
The ONC is already on the case, said Posnack.
“We know that there are ecosystems that support one type of resources and other communities that take different approaches to accomplishing their goals,” said Posnack.
“We are also well aware that the scope and scale of what a developer is trying to achieve will affect the decision-making process.”
“That’s why real-world testing is so important, and that’s one of the places the ONC can provide some guidance for the industry.”
In early October, the ONC announced the availability of the Inferno Testing Suite, demonstrating its ongoing commitment to the fiery theme as well as to real-world testing.
“The consumer-facing API is the common denominator, but beyond that, everyone has their own strategy.”
Inferno is designed to support developers as they create FHIR servers, or health IT systems from which apps and services will draw health data.
“Inferno offers a rich and rigorous set of testing tools to help health IT developers make sure the FHIR standard is consistently implemented,” Posnack and John Snyder, Senior Technical Advisor, wrote in a blog post on Health IT Buzz.
The ONC hopes that making these tools available to the broad and diverse community of developers creating FHIR-based applications will make it easier to avoid unnecessary variation in implementation.
“We’ve seen evidence that many developers have implemented the Argonaut specifications already,” noted Posnack. “That should hopefully provide a baseline experience for everyone.”
How FHIR is fueling real-world use cases
At the HL7 FHIR Applications Roundtable, more than 40 developers and their applications vied for the title of “best in show” for 2018.
The vast majority of FHIR-based tools were designed to make care more intuitive, more informed, and less fragmented for patients.
Data aggregators, care planning apps, and patient engagement tools offered to streamline interactions with providers and administrative staff, while risk score calculators and clinical decision support systems offered actionable insights to clinicians at the point of care.
Onsite equipment glitches notwithstanding, most of the developers were able to show working demos of their products, which are in various stages of commercialization and deployment. Many of the applications had won previous awards, including industry challenges set by the ONC.
There were no novelty oversized checks on the line for beating out the competition, and nothing more than a photo and a handshake from the judges for each day’s winners.
The bragging rights may have been nice, but the overall feeling of the event was that most of the developers were simply there to confirm with their colleagues and peers that FHIR is the real deal.
“There are so many people involved in using FHIR now, and it’s a very exciting area of innovation,” said Mark Scrimshire, who was tapped by CMS to help lead the development of Medicare’s Blue Button 2.0, a revamped version of the popular data sharing mechanism.
“There are literally thousands of developers who have made FHIR a priority, and they have nearly endless ideas for how to make applications that truly do advance care delivery and patient relationships with the healthcare system,” he said.
Blue Button 2.0 is a prime example of how FHIR-based APIs can build connections and enable new capabilities for providers and patients.
Not only can Medicare beneficiaries use the tool to download their personal health data directly from CMS to share with providers or keep for their own records, but developers, providers, and researchers can also take those data streams, analyze them, and return actionable insights to individuals through applications.
The option to access Medicare data straight from the source – with appropriate patient consent, naturally – has attracted significant interest from the IT community.
“We currently have about 1100 developers from 750 organizations playing with synthetic data available in the Blue Button 2.0 sandbox,” Scrimshire said.
“The data in the sandbox is representative of claims that they might see, but it has been created in such a way that it can’t be reconstructed or traced back to any actual beneficiaries. There’s no cost to the sandbox, and anyone can sign up. Serious developers will go through a verification process, but anyone can go to BlueButton.CMS.gov to sign up and have fun.”
Blue Button as a whole contains four years of Medicare Part A, B and D data related to 53 million Medicare beneficiaries.
That represents an immense wealth of data that can be used to address numerous industry use cases, says Scrimshire.
“One of the projects we’re very excited about is compatibility with what the National Institutes of Health and the All of Us research project are building,” he said.
“Researchers will be able to supplement the information they are collecting from participants with the claims histories from Medicare, which will offer so many opportunities to get to the heart of what precision medicine means.”
But with FHIR at its core, Blue Button 2.0 can also offer much more immediately tangible benefits to patients – and the providers who are increasingly financially responsible for their long-term outcomes.
“Value-based care has created a number of new challenges that we can solve with the right application of data exchange tools,” Scrimshire said. “Attribution within Medicare is a high-value pain point that FHIR can help alleviate.”
Patients receiving care in Medicare accountable care organizations (ACOs) are typically asked to choose a primary provider, he explained.
“Anyone can go to BlueButton.CMS.gov to sign up and have fun.”
If the patient doesn’t actively choose to attribute him or herself to a specific entity, Medicare will use claims patterns to assign a provider for that individual instead.
“Basically, they’ll make the most popular provider in your claims history your primary doctor, and assume that person should get your information,” Scrimshire said.
“Well, imagine if you receive a cancer diagnosis, and your cancer specialist becomes your de facto main provider. You’re likely going to be half way through your treatment before that oncologist gets your data from that passive attribution process.”
With Blue Button 2.0, that oncologist could ask the patient to share their full record as part of the patient onboarding process, he continued. That will allow the oncologist to have access to the individual’s claims and medication data immediately.
Source: Xtelligent Media
“Now your oncologist can ask you why you ended up in the ED a week ago, and she won’t have to wait to get an ADT alert that goes through your primary care provider – assuming the PCP and the oncologist have the data sharing capability and processes in place to share that information quickly,” said Scrimshire.
“And instead of leaving a financially at-risk provider in the dark for six weeks, two months, or longer, they can partner with the beneficiary to get better insights with less effort and tailor that care plan to the individual’s needs.”
Because Blue Button 2.0 is based on FHIR and other widely-adopted data standards, it allows providers to participate in similar health data exchange activities in a vendor-agnostic manner.
Cross-vendor functionality is also the goal for Geisinger Health System, which has actually chosen to re-develop two existing applications using FHIR to allow for broader commercialization, said Julie Rockey, Strategic Program Director at Geisinger.
“We knew that anything we created would need to be FHIR enabled if we wanted to sell it to other organizations,” she said.
Rockey spearheads a strategic collaboration between Geisinger and Merck aimed at developing and commercializing innovative workflow solutions.
“Our applications couldn’t be specific to the Epic installation we have here at Geisinger – they had to be applicable to all other EHRs out there which consume FHIR resources,” she continued.
“So even though we had two applications developed natively in our Epic Systems environment, they are being converted over to a FHIR foundation to make them accessible on a national scale.”
At the HL7 FHIR event, Rockey showcased two applications, the Family Caregiver App and MedTrue, both of which offer patient-facing and provider-facing components.
The Family Caregiver App is designed for the families and caregivers of high-needs patients with conditions such as cancer, Alzheimer’s, and complex pediatric conditions, she said.
“Our test population was patients in stages three and four of lung cancer. Typically these patients are getting multimodal therapy, such as chemo and radiation at the same time. On top of all their other appointments, this can be hard to schedule and manage.”
“So we created a calendar that integrated appointment data from our medical oncology platform to our radiation platform. We also enable integration with personal calendars like Google, Outlook, and Yahoo, so they can see their personal schedules in exactly the same place as their scheduled appointments across the system.”
Providers can also see these calendars, so they know not to double-book patients who may have limited time to accomplish personal tasks.
“Maybe they go to the gym every Tuesday and Thursday morning for a fitness class, and they really don’t want anything to interfere with the time they’ve scheduled to help get some exercise and feel better about themselves,” said Rockey.
Patients can also create medication schedules to help them stay adherent to regimes that are often extremely complicated.
“And then there’s the personal aspect of engaging in many relationships with a number of different providers,” she added.
“When we conducted focus groups, we found that patients wanted their providers to know something about them other than their diagnosis or treatment protocol.”
“We have a section of the application where they can record tidbits about their hobbies and their personal lives: their favorite sports teams or their dog’s name – there are about fifteen different options for preferences or interests.”
The information is displayed on the provider’s dashboard so that he or she can initiate a meaningful conversation with the patient.
“A real connection might help the patient feel more engaged and may lead to following that provider’s advice or instructions,” Rockey said. “Those are assumptions, but we are in the middle of an outcomes study that will help us fill in the gaps between hypothesis and reality.”
With complex patients who tend to spend great deal of time in hospitals, clinics, and offices, the patient experience can often be overlooked in favor of monitoring vitals and adjusting dosages of highly potent drugs.
“We know that the Family Caregiver App is not about managing hardcore, tangible clinical measures – this isn’t about tracking A1C or cholesterol,” she said.
“It’s about addressing those soft, squishy things that define the patient experience and may really impact an individual’s attitude towards care, towards the services we provide, and towards their ability to handle something that is turning their lives upside down.”
The MedTrue app also uses FHIR to create more meaningful patient experiences – this time while simultaneously tackling the multi-billion dollar problems of medication reconciliation and non-adherence.
“MedTrue allows patients to get an email up to two weeks before their visit asking them to confirm that the medications in their EHR record are still accurate,” said Rockey.
“The patient can look over the list from home, when they’re not rushed or anxious – they can go into their medicine cabinet and double check if they’re not sure about something – and confirm if the list is accurate or if it needs to be changed.”
The app also integrates data from Surescripts to ensure that medications prescribed by external providers are still available to Geisinger clinicians.
“It’s about addressing those soft, squishy things that define the patient experience.”
MedTrue also collects fill rate data from Surescripts, allowing providers to check if patient-reported medications adherence information is backed up by the pharmacy.
“If an individual’s Surescripts data says the fill rate is 50 percent, but the patient reported taking the medication all the time exactly as prescribed, the provider can start probing that disconnect and ask the patient if they understand how they’re supposed to take it or if there’s something stopping them from taking the medication according to instructions,” Rockey explained.
Both apps display their provider-facing data directly into the health system’s Epic EHR, she said.
“It’s an iFrame right in their workflow, so they don’t have to go to another place to start having these conversations,” said Rockey.
“We know it’s important to make it easy to see and easy to work with, because that allows the user to really engage with the data without spending time figuring out how to look at it and how to get back to what they were doing before.”
A bright future for FHIR as a tool for population health
The applications on display at HL7’s events are only the beginning for FHIR, says Wayne Kubick, Chief Technology Officer at HL7 International.
“FHIR is not an emerging standard anymore,” he said. “It’s solving real problems in real healthcare environments. There is a very dynamic and energetic community that is actually building FHIR solutions, both in the US and around the world, and they are about to unveil what’s next.”
There are currently three versions of FHIR, with most developers working with Release 2 or Release 3, Kubick explained.
Of the ten EHR vendors with the largest market share, all of which use FHIR, nine have deployed their products using Release 2 and only one, eClinicalWorks, is reliant on Release 3.
Release 3 was published in March of 2017 as the first release to take FHIR out of “draft” status, but the community is already eager to move on to the next step.
“We’re planning to get Release 4 out the door by the end of the year,” he said. “It will be a very important accomplishment. Release 4 will have normative content and metrics that will help it become a stable baseline to allow everyone to catch up. Then, the next major swath of development will be to try to flesh out the clinical content resources.”
“We really want to refine some of the resources associated with the US Core Data for Interoperability (USCDI) data set, formerly known as the Common Clinical Data Set (CCDS), and work on a few clinical concepts that aren’t in the USCDI but that are important for clinical care or for research.”
“FHIR is not an emerging standard anymore. It’s solving real problems in real healthcare environments.”
The Argonaut Project is also busy making improvements to FHIR’s capabilities, says Tripathi, and three of the group’s major initiatives have the potential to be game-changing for population health management.
“Right now, the consumer-facing APIs based on FHIR only allow you to move data for one person at a time,” he said. “That’s adequate for the job the API is supposed to do: to enable access to personal health data.”
“But what if I’m a health plan with 1000 patients in a health system, and I want to use an API to get clinical data from all of those individuals so I can conduct risk stratification or some sort of outreach program? We can’t do that at the moment with FHIR, which is why we are working on a bulk data access capability.”
The implementation guide for bulk data access is expected to be completed in December or January, Tripathi says, and the document will then be turned over to HL7 for validation.
Argonaut members are also exploring how to bring clinical notes along for the ride.
“The original data query implementation guide, the one that’s the basis for the Apple implementation and most of what the EHR companies are doing, is based on the USCDI,” Tripathi explained. “There are 22 structured data elements including labs, problems, and demographics – but it doesn’t include notes.”
“Clinical notes are very important for a lot of reasons, and patients are sometimes confused that they’re not included when they download their record from somewhere. Lab results are great, but they want to know what their clinicians think and what they’re really saying.”
Adding a clinical notes functionality to the implementation guide will allow patients to receive their discharge summaries, radiology reports, operative notes, and other unstructured data when they request access to their records through a consumer-facing API.
Lastly, but certainly not least, is the ability for providers to field FHIR-based questionnaires.
In his leadership role at MAeHC, Tripathi works with regional stakeholders to foster health information exchange, ongoing health IT adoption, and enable analytics services.
“Lab results are great, but [patients] want to know what their clinicians think and what they’re really saying.”
The organization is currently collaborating with the state of New Hampshire on a DSRIP Medicaid project focused on substance use disorder (SUD) and behavioral health.
“One of the requirements for participating providers is that they do a Comprehensive Core Standardized Assessment of every Medicaid patient with an SUD or behavioral health disorder,” said Tripathi.
“The idea is to collect more standardized information on the social determinants of health, because we know those insecurities can hugely contribute to a person’s ability to make progress against his or her condition.”
The social determinants of health, such as food and housing insecurity, health literacy levels, and access to transportation, are some of the most difficult data points to collect.
Few standardized databases are available to capture community-level statistics, let alone accurately delve into the individual challenges facing a person with a substance abuse disorder.
“New Hampshire needs to collect information on ten domains, but most of them are not standardized in any EHR,” Tripathi said.
“So even though New Hampshire has a relatively high level of EHR adoption, we would have to create custom forms for each vendor and implement them basically one by one across the entire state. If you’re facing something like that, you might think you’re better off doing it on paper – and you might be right.”
With a FHIR resource, the Department of Health and Human Services in New Hampshire could create a single list of questions and electronically share the questionnaire with hospitals and health systems in the state using any of the major EHR vendors such as Cerner and Epic.
“Those systems could just consume the form and render it within the EHR, so that the clinician could have electronic access to all the questions in the right order and preserve all the hierarchy and taxonomy used by the experts who created them,” Tripathi asserted.
“Now you’ve got a way to ask all the same questions in exactly the same manner across the entire state, and the data can be exported back to whoever is in charge of analyzing the results without worrying about variation or the integrity of the data.”
“Think about all the unstructured questions we want to ask – the use cases for population health are absolutely endless. I think this is one of the most exciting things we’ve done so far with FHIR.”
By combining the FHIR-based questionnaire capability with the bulk data access feature that allows the movement of data at scale, organizations will be able to generate, consume, and analyze structured socioeconomic data to inform interventions and strategies.
“That is basically going to solve a lot of the population health analytics problems we’ve been struggling with,” Tripathi said.
Shaping a new ecosystem of patient-centered healthcare
Over the past several months, CMS has made it extremely clear to industry stakeholders that expanding patient data access will be its main priority for the foreseeable future.
At the HIMSS Exhibition and Convention in March of 2018, CMS Administrator Seema Verma set a high bar for providers, vendors, and payers by announcing the MyHealthEData initiative, a broad federal push to enable more consumers to engage effectively with their data and their care.
“When we go to the doctor’s office, we want to be able to have the information about what happened there,” said Verma to HealthITAnalytics.com just after the announcement.
“We want to be able to build our record from birth through your entire life. You want to be able to aggregate information from your medical record and from devices so you can put that story together and see what your health looks like. So we’re doubling down on these efforts.”
Blue Button 2.0 will play a major role in that mission, as will FHIR in general, said Steven Posnack from the ONC.
“As we start to work through the underlying technical issues around data sharing, we are focused on a goal of enabling transparency for consumers that can help them shop for care and ultimately be in the driver’s seat when it comes to their own health data,” he said.
“That will create a more competitive marketplace for health IT, and by extension, there will be more competition around the delivery of quality care, which is good for patients.”
But enabling access is only one step towards generating a truly patient-led healthcare system, asserted Scrimshire.
“Seema Verma has really put the industry on notice that now is the time to enable data access for patients. But why do we want to empower patients by giving them access to their data? Do they want their data?” he asked.
“Well, no, they don’t. What they want is a way to do something with their data, and that is what FHIR-based applications are starting to create.”
Scrimshire envisions an emerging ecosystem of applications and organizations that act as “digital concierges.”
“Patients will find an option that they trust, and that entity will sort out the technical issues and make sense of everything so that the data will get where it needs to do,” he predicted.
“Whether that’s just bringing up something on our smartphones or engaging with something at the health system level remains to be seen. But regardless, it’s the work of the FHIR community that is creating an environment where any of this can happen.”
The high level of developer engagement may be just as important as patient engagement for architecting a data-driven ecosystem that has a chance of achieving some of the healthcare industry’s biggest objectives, he added.
“It’s the work of the FHIR community that is creating an environment where any of this can happen.”
“HL7 has made sure to offer a lot of options for developers to come together and make FHIR work. They have given people a real voice, and that has prevented FHIR from being a standard that is imposed by the powers-that-be,” he observed.
“Instead, FHIR is something that has bubbled up from the bottom, and that makes it much more likely to truly succeed in the long term.”
Widespread federal support certainly can’t hurt, added Kubick, especially since FHIR has already found a firm footing in the health IT environment.
The extra push from CMS, the ONC, and other major stakeholders will only accelerate innovation and real-world implementations.
“More and more data is becoming available, and FHIR gives people a method of getting that data in a more consistent manner,” said Kubick.
“It won’t solve all our problems – FHIR won’t do anything to improve data that is messy or incomplete to begin with – but it’s far and away the most effective thing we’ve done for interoperability to date.”
“The fundamental infrastructure is in place. The data is starting to flow. We’ve seen a lot of positive developments over the past few months, and it’s all very exciting. But I can promise you – this is all just the tip of the iceberg.”