Info Ex­change, Stan­dard­ized

The FHIR in­ter­op­er­abil­ity stan­dard reaches a tip­ping point in 2018, as adop­tion rises and a key vote looms.

Health Data Management - - CONTENTS - BY GREG SLABODKIN

Fast-ris­ing adop­tion of the FHIR stan­dard means po­ten­tially swift ad­vances in pa­tient-fo­cused data in­ter­op­er­abil­ity and ac­cess.

2018 is shap­ing up as a piv­otal year for Health Level 7 In­ter­na­tional’s Fast Health­care In­ter­op­er­abil­ity Re­sources ap­pli­ca­tion pro­gram­ming in­ter­face. Sig­nif­i­cant mo­men­tum con­tin­ues to build as more use cases in­di­cate FHIR has reached a tip­ping point as a ma­ture stan­dard for the elec­tronic ex­change of health in­for­ma­tion.

In March, Ap­ple launched an en­hance­ment to its Health app—which lever­ages FHIR—en­abling pa­tients at 39 par­tic­i­pat­ing U.S. health­care or­ga­ni­za­tions to view their med­i­cal records on their iPhones af­ter up­dat­ing to the iOS 11.3 mo­bile op­er­at­ing sys­tem.

The en­hanced Health Records sec­tion within the Health app al­lows pa­tients to see med­i­cal data— en­crypted and pro­tected with their iPhone pass­codes—gath­ered from var­i­ous in­sti­tu­tions and pre­sented in a sin­gle, ag­gre­gated view. Pa­tients also re­ceive elec­tronic no­ti­fi­ca­tions when their records are up­dated by providers.

“I’m de­lighted at the way FHIR has been able to trans­form pa­tient ac­cess to data,” says Chuck Jaffe, MD, HL7’s CEO. “It’s only the be­gin­ning of a new era of in­ter­op­er­abil­ity and trans­parency. It goes be­yond sim­ply ac­cess­ing data be­cause in the fu­ture there will be solutions for clin­i­cal de­ci­sion sup­port, in­te­gra­tion of ge­nomic data, and large-scale pop­u­la­tion health mea­sures—all of which are sup­ported and this is the only the first step.”

Adding to the mo­men­tum, in March the De­part­ment of Veter­ans Af­fairs— the na­tion’s largest in­te­grated health sys­tem—launched the VA’s Open API Pledge initiative in which health­care

or­ga­ni­za­tions are vol­un­tar­ily col­lab­o­rat­ing with the agency to map health data to in­dus­try stan­dards. Specif­i­cally, the initiative calls on providers to sup­port cur­rent and fu­ture ver­sions of FHIR.

So far, 11 ma­jor or­ga­ni­za­tions have signed the pledge, in­clud­ing Cleve­land Clinic, Geisinger, In­ter­moun­tain Health­care, Mayo Clinic, Part­ners Health­care and the Univer­sity of Pitts­burgh Med­i­cal Cen­ter. They have com­mit­ted to work­ing with the VA and stan­dards com­mu­nity to im­ple­ment the ex­ist­ing Arg­onaut Project im­ple­men­ta­tion guides for the FHIR API.

The Arg­onaut Project is a col­lab­o­ra­tion of health IT ven­dors and providers seek­ing to ac­cel­er­ate the adop­tion of FHIR by cre­at­ing “road-tested” im­ple­men­ta­tion guides ac­ces­si­ble to de­vel­op­ers in or­der to build in­ter­op­er­abil­ity capabilities ac­cord­ing to modern In­ter­net ar­chi­tec­tures.

“This is an im­por­tant lever that can help to move things for­ward in an in­dus­try that is so frag­mented,” says Micky Tri­pathi, man­ager of the Arg­onaut Project. “The VA Open API Pledge initiative could be re­ally big. And, in the case of Ap­ple, that’s huge also be­cause it’s a val­i­da­tion from a tech­nol­ogy leader out­side of health­care that the stan­dard is ma­ture enough.

“What Ap­ple has done is very pos­i­tive for the in­dus­try be­cause in­stead of im­ple­ment­ing a pro­pri­etary stan­dard they have adopted the Arg­onaut im­ple­men­ta­tion guide,” adds Tri­pathi, who says the tech gi­ant has in essence be­come a test­ing plat­form for FHIR. “Ap­ple, then, be­comes sort of the bench­mark or lit­mus test for test­ing con­for­mance with the stan­dard.”

With par­tic­i­pants such as Ac­cen­ture, athenahealth, Beth Is­rael Dea­coness Med­i­cal Cen­ter, Cerner, Epic, In­ter­moun­tain Health­care, Mayo Clinic, Meditech, McKes­son, and Part­ners Health­care, the Arg­onaut Project has gained sig­nif­i­cant trac­tion in de­vel­op­ing im­ple­men­ta­tion guides for their FHIR im­ple­men­ta­tions. The in­ter­op­er­abil­ity frame­work lever­ages the lat­est web stan­dards in­clud­ing a REST­ful API, which is de­signed to use less band­width than typ­i­cal ac­cess pro­to­cols and be more suit­able for web use.

“It’s not that the Arg­onaut Project

‘26-year-olds in a garage’ will cre­ate ‘novel apps’ that ‘de­liver far more us­abil­ity’ on which to base tai­lored treat­ment pro­grams.

has re­ally good sub­ject mat­ter ex­perts who can write re­ally good im­ple­men­ta­tion guides,” says Tri­pathi, who is also pres­i­dent and CEO of the Mas­sachusetts eHealth Col­lab­o­ra­tive. “It’s that we bring to­gether all of those ven­dors and provider or­ga­ni­za­tions to scale it across the in­dus­try.”

As a mem­ber of the Arg­onaut Project, Cerner sees its EHR sys­tem emerg­ing as a tech­nol­ogy plat­form for a plethora of apps that lever­age FHIR, en­abling physi­cians to ac­cess th­ese plug­gable apps di­rectly within their work­flow to more eas­ily vi­su­al­ize, in­ter­act with and trans­mit health data. “We’re re­ally look­ing at this as Cerner is a plat­form ver­sus a prod­uct so­lu­tion,” says Zane Burke, pres­i­dent at Cerner. “We’ll know we’re there when you see a lot of apps on our plat­form.”

The ven­dor is en­cour­ag­ing third-party de­vel­op­ers to build Sub­sti­tutable Med­i­cal Ap­pli­ca­tions and Re­us­able Tech­nolo­gies (SMART) on FHIR apps on top of Cerner’s Mil­len­nium EHR and HealtheIn­tent pop­u­la­tion health plat­forms. So far, it has 20 val­i­dated apps, Burke says.

With the emer­gence of REST­ful APIs lever­aged by FHIR, cloud ser­vice providers and ma­chine learn­ing, John Halamka, MD, chief in­for­ma­tion of­fi­cer at Bos­ton’s Beth Is­rael Dea­coness Med­i­cal Cen­ter, be­lieves the in­dus­try “sud­denly has the per­fect storm for in­no­va­tion.”

Halamka, co-author of Re­al­iz­ing the Prom­ise of Pre­ci­sion Medicine: The Role of Pa­tient Data, Mo­bile Tech­nol­ogy, and Con­sumer En­gage­ment, con­tends that in­no­va­tive third-party apps, mod­ules and ser­vices will layer on top of ex­ist­ing elec­tronic health records.

How­ever, he in­sists that EHRs—in their own right—will not serve as the most valu­able tools for per­son­al­ized care tai­lored to in­di­vid­u­als. “Epic, Cerner, Meditech, athenahealth, eClin­i­calWorks—they’re all fine, but do I be­lieve that they are go­ing to be the place where we see th­ese in­no­va­tions? I don’t,” says Halamka. In­stead, he con­tends that “26-year-olds in a garage” will cre­ate “novel apps” that “de­liver far more us­abil­ity and util­ity.”

His vi­sion is of a thriv­ing app ecosys­tem that pro­duces “Lego build­ing blocks” that will “sit around the

EHR and pro­vide this ad­di­tional func­tion­al­ity,” cre­at­ing in­di­vid­u­ally tai­lored pro­grams to treat a va­ri­ety of dis­eases.

“We’ll leave in place the EHRs we have, but sur­round them with th­ese kinds of com­po­nents so our clin­i­cians and our pa­tients will have a sim­i­lar ex­pe­ri­ence with cloud-hosted ser­vices,” he ex­plains. “It’s a bit like the iPhone and the App Store. The EHR is the iPhone and the iPhone is only valu­able to­day be­cause of the thou­sands of apps we can buy and add to it.”

In this sce­nario, Halamka en­vi­sions EHRs us­ing FHIR Clin­i­cal De­ci­sion Sup­port Hooks to send salient pa­tient data to cloud-hosted ser­vice providers that cu­rate the med­i­cal lit­er­a­ture and not only pro­vide a li­brary of ev­i­dence but grade the ev­i­dence for ac­cu­racy, im­pact and rel­e­vance.

Cerner’s Burke says he is op­ti­mistic about the po­ten­tial for progress in achiev­ing in­ter­op­er­abil­ity in­dus­try­wide in mean­ing­ful ways. “The VA, the Arg­onaut Project, and work that’s been done with Com­monWell [Health Al­liance] and oth­ers is re­ally com­ing to­gether around open stan­dards—and I think th­ese things will con­tinue to evolve.”

APIs are in­cluded in the 2015 Edi­tion of Health IT Cer­ti­fi­ca­tion Cri­te­ria re­quir­ing cer­ti­fied EHRs to demon­strate the abil­ity to pro­vide a pa­tient-fac­ing app ac­cess to the Com­mon Clin­i­cal Data Set via an API.

“ONC didn’t spec­ify that the API has to be FHIR,” notes Tri­pathi. How­ever, he says based on the lat­est data “some­thing on the or­der of 110 to 120 EHR ven­dors have cer­ti­fied their sys­tems with a con­sumer-fac­ing API—and some­thing like 50 per­cent of those are FHIR-based APIs.”

“The fact is that you just have to have an open API—you don’t have to use FHIR,” com­ments HL7’s Jaffe. “Why you would want to do that, I don’t know.”

HL7 has pub­lished a US Core Im­ple­men­ta­tion Guide—de­vel­oped in as­so­ci­a­tion with the Of­fice of the Na­tional Co­or­di­na­tor for Health IT— that de­fines the min­i­mum con­for­mance re­quire­ments for ac­cess­ing pa­tient data as de­fined by the Arg­onaut pi­lot im­ple­men­ta­tions and the ONC’s 2015 Edi­tion Com­mon Clin­i­cal Data Set.

More im­por­tantly, last year HL7 pub­lished Re­lease 3 of its FHIR Stan­dard for Trial Use (STU), mov­ing closer to a nor­ma­tive ver­sion of FHIR.

“My as­pi­ra­tion is to see FHIR Re­lease 4 come out at the end of the year—cer­tainly we’ll bal­lot it at the end of the year,” says Jaffe. “It’s an op­por­tu­nity for nor­ma­tive re­sources for back­ward com­pat­i­bil­ity for the kind of in­sur­ances the devel­op­ment com­mu­nity re­quires for mak­ing in­vest­ments in any tech­nol­ogy.”

Re­lease 4 is ex­pected to be the first nor­ma­tive ver­sion of FHIR “where the stan­dard be­comes sta­ble, and break­ing changes are no longer con­sid­ered,” notes Gra­ham Grieve, FHIR’s prod­uct di­rec­tor. □

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