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FHIR Takes Off as ONC Teases Upcoming Data Blocking Definitions

Steven Posnack explains how FHIR is taking hold as the industry eagerly awaits the ONC's proposals to tackle data blocking and other interoperability concerns.

FHIR, data blocking, and the ONC

Source: ThinkStock

By Jennifer Bresnick

- Healthcare organizations that have been looking for a way to spark widespread, seamless health data exchange may have finally found their fuel in FHIR.

Adoption of the Fast Healthcare Interoperability Resources has spread like…well, you know…across an industry that has been anxiously seeking the interoperability capabilities to support pay-for-performance reimbursement, population health management, and new strategies for reducing costs.

Close to 80 percent of hospitals and MIPS eligible clinicians are currently using health IT tools that have FHIR capabilities, according to a new blog post from officials at the Office of the National Coordinator (ONC), giving them the ability to engage in interoperability with their patients and their peers.

Steven Posnack, Director of the Office of Standards and Technology at ONC
Steven Posnack, Director of the Office of Standards and Technology at ONC Source: ONC

Eighty-seven percent of hospitals and 69 percent of clinicians have adopted EHR and other health IT tools from vendors that incorporate FHIR into some aspect of their offerings, said Steven Posnack, MS, MHS, Director of the Office of Standards and Technology, and Wes Barker, a program analyst at HHS.

Many of the industry’s big-name technology providers, including Epic Systems, Cerner Corporation, Allscripts, and MEDITECH, have committed to using the internet-based data exchange standard in their products.

READ MORE: FHIR Finally Brings the Internet to Bear on Healthcare’s Big Data

As a result, FHIR has been gaining steam as the data exchange standard of choice over the last several years. 

FHIR received a huge boost in 2014, when the Argonaut Project was launched to develop industry consensus around FHIR specifications that could be used to meet the 2015 Edition Certified Electronic Health Record Technology criteria for application programming interface (API) capabilities.

Since that time, both the ONC and a growing number of private entities have embraced FHIR as a flexible way to exchange discrete data elements across disparate systems and meet federal guidelines for interoperability.

In fact, just under a third of health IT developers with 2015 Edition CEHRT products used FHIR to attest the API requirement. 

“While the 32 percent may seem low, the estimated market share of the health IT developers using FHIR is large. About 82 percent of hospitals and 64 percent of clinicians use these developers’ certified products,” Posnack and Barker pointed out.

READ MORE: As FHIR Matures, Healthcare Interoperability Comes into Focus

This broad adoption at the commercial level is especially encouraging in light of the fact that the ONC is just weeks away from releasing its proposed rule around data blocking to the public, said Posnack in an exclusive interview with

EHR vendors and their customers adopting FHIR capabilities

Source: ONC

“FHIR has become very popular very quickly,” he said. “In healthcare, you only get one chance to get it right, sometimes.  That’s even more true when you have so much attention and hype around a new technology.” 

“That’s why we need to make sure that we can support the needs of the community as FHIR moves forward.  Every stakeholder, public and private, needs to ensure that the applications being developed can directly support real business needs.”

The ONC’s upcoming proposals will help to create those guardrails for the industry as it explores how to best implement consumer-friendly interoperability technologies while ensuring privacy and security in a quickly changing environment.

Speaking at the HL7 FHIR Applications Roundtable in Washington, DC on September 28, Posnack stated that the ONC’s draft rule is currently under review from the Office of Management and Budget (OMB).

READ MORE: Da Vinci Project Brings HL7 FHIR to Payers for Big Data Analytics

The rule, containing proposals related to a number of directives contained in the 21st Century Cures Act of 2016, was submitted on September 17. 

The OMB has 90 days to review the document.  Assuming the federal office takes all the time allotted, the proposed rule should be released to the public in the middle of December.  The ONC will then take public comment and finalize the rule, fulfilling a number of instructions from Congress.

“The 21st Century Cures Act gave ONC some new responsibilities to implement,” Posnack explained. 

“Congress asked us to focus on a few key areas, including information blocking, real-world testing, and the idea of being able to access application programming interfaces (APIs), ‘without special effort.’  I put that last phrase in air quotes, because that is the language they used in the bill and it has sparked a lot of conversation in the industry.”

Posnack believes that Congress chose the phrase after reviewing the ONC’s landmark report on information blocking from 2015. 

The report prompted fierce debate around data blocking and whether or not vendors were intentionally clinging to proprietary standards in an effort to gain a competitive edge in a challenging marketplace. 

Hospitals adopting FHIR-enabled EHR technologies

Source: ONC

The ONC report also called out EHR vendors for requiring high data exchange fees and using convoluted contracting terms that created walled gardens and data siloes, leaving providers ill-equipped to participate in the burgeoning value-based care environment.

Coincidentally or not, vendor efforts to promote standards-based data exchange ramped up significantly after the report’s release, culminating in an HHS-sponsored pledge in 2016 to improve the flow of information across the major EHR brand names.

During that time, almost all of the major vendors took on active roles in industry consortia designed to break down barriers to data exchange, and worked hard to turn open data exchange – and FHIR-based interoperability in particular - into a selling point for their products.

Posnack believes that their efforts have already started to pay off.

“It doesn’t always feel like the industry is changing very much, but it really has made quite a bit of progress around interoperability,” he asserted.  “You can look at some of the work done by the Sequoia Project, Carequality, CommonWell, and SHIEC – all of them have helped mature the overall network infrastructure and expand the accessibility of health IT.” 

“When you start to layer in the public and private work around FHIR, such as the Argonaut Project, it’s very clear that the industry is poised to continue moving in the direction of interoperability much more quickly than it has.”

That doesn’t mean that the proposed data blocking rule is now superfluous.  Numerous challenges remain across the industry, and new questions about data portability are likely to arise as patients become more involved in moving and sharing their data.

“We want to look at how we can best serve the market by adding transparency,” said Posnack.  “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.”

“There’s an expectation that a lot of the engagement opportunities from other industries – banking, Amazon, Facebook, et cetera – should be available in healthcare right now.  There’s a gap between what we can do in our other consumer interactions and what we can do in healthcare.  We’re trying to close those gaps.  And we are, in fact, making progress every year.”

Clinicians using FHIR through their EHR vendor product offerings

Source: ONC

The pending proposals around data blocking, health IT certification, and other Cures Act issues will be part of that ongoing effort, said Posnack, and all industry stakeholders are strongly encouraged to participate in the process of crafting the finalized guardrails for developers and providers.

The ONC reads every comment submitted on proposed rules, he added. 

“We read every single one of them.  It’s our duty and obligation under the regulatory procedures to summarize the comments and provide responses,” said Posnack.  “Whether they’re one page or 80 pages, we go through everything we receive.  Sometimes industry comments help us clarify the policy we were proposing before we finalize it, which helps everyone.” 

The ONC’s online feedback form is available to all members of the healthcare ecosystem, including providers and patients, and offers the ability to provide comments on a wide variety of health IT issues, from FHIR and information blocking to potential HIPAA violations and EHR usability.

“We haven’t gotten as much engagement from the startup community or the provider community as we would like,” he acknowledged.  “We want to change that by actively asking stakeholders to contribute in whatever way they can.  They can do that by directly sending us comments, or they can remain in active communication with their health IT developers and provide insights that way.” 

“If there are stakeholders out there that don’t see their needs being fully addressed, we absolutely welcome all of them to the table,” he stressed.

Industry engagement is vital as providers and developers enter a pivotal year for technology adoption and regulatory compliance.

“We are at a critical point as we move into 2019,” he said.  “A lot of the program compliance timelines are shifting into active gear in 2019, specifically around the Promoting Interoperability program and the requirements for 2015 Edition CEHRT systems.”

“The proposals that we will include in our pending proposed rule will affect the entire healthcare ecosystem.  So I want to take every chance I get to urge everyone to get involved.  Take this opportunity to get your voice heard, because it will have an impact.”


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