January 2019

FHIR Blazes New Path Toward Interoperability
By Selena Chavis
For The Record
Vol. 31 No. 1 P. 14

Industry leaders weigh in on the promise of the evolving IT standard.

Interoperability remains one of health care's greatest challenges as well as one of its greatest opportunities. While not a panacea, the introduction of a new IT standard in recent years—FHIR—has many hopeful about where health information exchange is headed.

Pronounced "fire" and serving as the acronym for Fast Healthcare Interoperability Resources, FHIR is an independent standard that allows greater flexibility and simpler integration by using a set of routines, protocols, and tools for building software and applications known as RESTful application program interfaces (APIs).

"Right from its inception, it was fairly evident that FHIR could help overcome some of the limitations of earlier standards like HL7 v2 and v3, Clinical Document Architecture (CDA), and Consolidated CDA while enabling a new API-driven ecosystem for health care data exchange," says Swanand Prabhutendolkar, vice president of data management at CitiusTech.

Wayne Kubick, chief technology officer at Health Level Seven International (HL7), notes that the standard is opening a whole new world of practical uses that hold great promise for care delivery. "One of the things we do at HL7 is the FHIR Applications Roundtable where we showcase how groups are using FHIR in innovative ways," he says. "There has been an explosion of creativity and entrepreneurship. We're just scratching the surface now."

For instance, Iris Chatbot was recognized at the roundtable event in 2017 for leveraging FHIR within a platform that enables appointment scheduling and medication refill orders within Facebook Messenger or iMessage. SyntheticMass, a public FHIR server and tool hosting clinical data for 1 million synthetic simulated patients within Massachusetts, was also showcased for its innovation.

Prabhutendolkar believes FHIR's use will continue to expand in innovative ways, noting that the standard's API-driven design allows for a much higher level of standardization and extensibility across a diverse ecosystem of clinical information. "With FHIR, we can now implement use cases that were a bit more challenging with the earlier standards. Areas like clinical decision support, preventive care, population analytics, custom notifications, consumer device integration, personal health records, diagnostics, and more will see strong value addition from FHIR," he says.

While FHIR was introduced in 2011 by HL7, its first standards for trial use were released in 2017. "Since then, we have seen a significant open community, led by HL7 and others like the Healthcare Services Platform Consortium, build up around the standard," Prabhutendolkar says. "While we may not see established standards like [HL7] v2 and v3 or CDA being replaced anytime soon, FHIR has clearly become the next-generation, consensus-driven standard that HL7 is looking at to drive the interoperability story."

FHIR's Evolution
John D'Amore, president and chief strategy officer at Diameter Health, says FHIR was born from a need to introduce more advanced, modern information infrastructures in health care. "HL7 does a lot of research to keep up with trends and where the industry is headed," he explains, pointing out that the HTML and XML standards introduced in early meaningful use stages were already outdated when the requirements came on the scene. "Clearly HL7 and others saw the need for medical standards to keep up with [technological advancement]. FHIR started independent for a couple of years and was pulled into HL7 and quickly embraced during the 2013 timeframe."

Kubick says FHIR was part of HL7's natural evolution. While HL7 v2 worked well in the early 1990s as the first health care standard for point-to-point communication, the v3 was developed to more effectively address the goals of interoperability in the 2000s. Yet, adoption of the new HL7 standard lagged due to the offering's complexities.

"Throughout the first decade, there was a lot of investment, and, at the time, HL7 thought v3 would be the answer to everything," Kubick recalls. "While it was a brilliant and ambitious quest, in practice it turned out to be extremely complex. There were very few people who really understood it."

Prabhutendolkar points out that the discussion quickly evolved to include scenarios which HL7 standards could not address, such as wearable device integration, custom analytics, and the development of PHRs. Advancing interoperability to address growing collaboration, access, and analytics needs required moving to a standard that people would actually use to solve business problems—one built on the RESTful APIs commonly used to design today's internet and web platforms.

Since its inception, FHIR has undergone four major releases (the fourth edition was released this month). In addition, Prabhutendolkar notes that the industry is also watching the evolution of SMART on FHIR, a technology stack that takes advantage of FHIR to enable data/user interface integration, API management, and data connectivity between health care applications such as EMRs, analytics platforms, and patient portals.

What Makes FHIR Unique?
According to Kubick, by incorporating the latest technological advancement, FHIR speeds the design of applications—hence, the use of "fast" in the standard's name. It was also designed for specific use in the health care market, not to address broad industry use cases.

"You could build things quickly," Kubick explains, noting that there are more than 100 building blocks available specifically geared to the needs of health care. "FHIR offers the latest technology plus health care–related concepts that give developers the ability to put pieces together and solve problems."

With FHIR, the technology construct for health care data interoperability changes dramatically, Prabhutendolkar says, explaining that a REST-based foundation strongly aligns with today's technology needs and architectural trends, making it much easier to implement and manage. "With more EMR vendors embracing FHIR standards, the interoperability community is poised to make data transfer a truly seamless process," he says.

Another critical FHIR feature allows developers to build standardized browser applications that are familiar to end users. And it's human readable, according to Adam Boris, board advisor to Carefluence and partner at TechCXO, eliminating the problems associated with other standards that deliver complex, lengthy documents that often contain at least some machine readable text.

Offering an example, Boris points out that if a patient information query is made to a hospital through an application powered by FHIR, it will tell the user in plain, readable English what type of data are available within the browser. In addition, FHIR can be consumed in small bites such as a medication record. Instead of physicians having to retrieve information from a lengthy document, the specific information is made immediately available, improving workflow and the probability that the information will be used.

"It really brings EMRs into the internet age," Boris says.

FHIR solves many of the transport problems inherent in previous interoperability standards at the same time it addresses some of the issues associated with semantics and content, D'Amore says. "Transport and transaction is easier because the API actually gives you the format for how you're going to call the system and receive the information back … and it takes care of the authorization layer," he explains. "It's a great advancement."

FHIR is open source and available to everyone. "There are no restrictions on it," Kubick emphasizes. "I came from standards organizations in the world of pharmaceutical research. We never had anything like FHIR where there is an active community of thousands of people around the world who are interacting directly."

Pros and Cons
Because FHIR is an early and rapidly evolving standard, the industry will face some growing pains, Boris says. For example, not all of the 60 or so resources are as evolved as others. While basic resources such as patient visit history and medication allergies are mature across FHIR applications, others are not. Also, the introduction of the fourth version of FHIR means there will be many different representations of the standard, which will likely produce costs for the industry.

In addition, because FHIR allows developers greater ability to customize endpoints from a terminology perspective, there will be differences in the way terminologies are represented, opening the door to problems with semantics across EMRs. "There's going to be an evolution for data normalization," Boris explains, adding that "it's a solvable problem."

D'Amore uses an analogy of water purification to explain FHIR's status. "Water needs to go through pipes before you drink it, and you want to make sure it's clean," he explains. "FHIR is going to make the pipe for health data so much bigger, but it's not going to make the water cleaner. People have a misperception that it's going to be a panacea."

In other words, FHIR actually delivers more variation in terminology, he says.

Industry professionals overwhelmingly agree that the pros associated with FHIR far outweigh the cons. In fact, Boris suggests that the introduction of FHIR has gone much differently than many new standards because the entire industry is behind it.

Since FHIR is a new and evolving standard, Prabhutendolkar says it is unfair to state benefits and gaps in black and white without significant industry adoption and validation. At the same time, he believes there is industry consensus around a few benefits, including the following:

• Because it uses a RESTful API-driven architecture, implementation is faster and more fluid.

• Custom use cases are easier to build and scale without having to undergo a massive integration effort, eg, health care analytics, clinical decision support, real-time alerts, and notifications.

• Unlike earlier standards, the data resources are intuitive and it's possible to incorporate new ones, such as consumer-generated data (from apps, wearables, sensors, and biometric devices), within clinical workflows in a secure, compliant manner.

• It enables the creation of a dynamic health care app ecosystem that can leverage a diverse pool of resources.

Gaining Momentum
In terms of adoption, Kubrick is optimistic about the direction FHIR is headed. "I think it's done extremely well given the magnitude of what's trying to be done," he says. "What we are seeing is when people become familiar with FHIR and what they can do with it, they get rapidly excited about it."

A recent analysis conducted by the Office of the National Coordinator for Health Information Technology (ONC) reviewed how HIT developers used FHIR to meet 2015 Edition certification requirements, which include demonstration of API. The ONC also assessed how hospital and clinician access to 2015 Edition certified APIs varies across the country.

According to the report, approximately 32% of certified HIT vendors are using FHIR, and nearly 51% of HIT developers are using some version of FHIR. In addition, the 10 certified HIT vendors with the largest market share across hospitals and clinicians use at least the second release of the standard.

Prabhutendolkar points out that consumer device and mobile phone companies that have been peripheral players for a long time are taking the lead and contributing significantly to FHIR adoption. "The Apple Health Records API and its EHR Data Viewer is a great example how FHIR helps aggregate clinical and other data into a single interface," he says. "Apple initially worked with EHR leaders like Epic and Cerner to create a set of APIs and interfaces that could make this happen. At last count, there are more than 80 organizations that have connected through the Apple Health Records API."

Boris believes that increased competition in the market and evolving consumerism trends will further advance adoption. "It may take three to five years to fully unfold, but there is going to be some big developments about patient access and new ways of doing business in health care," he says. "Everyone is talking about patient engagement, patient activation, and having a connection to patients beyond the actual time during a visit. Consumerism in health care is lining up FHIR, which is an enabler of that."

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications, covering everything from corporate and managerial topics to health care and travel.