The Cocktail Party Survival Guide to FHIR
The cocktail party or networking event can be a daunting activity for healthcare professionals. Armed with only an imported beer and bacon-wrapped shrimp, we’re supposed to go talk with strangers about work for hours. Topics might include: how are you? What problems are you working on? And what do you think about FHIR?
But what if you’re not up to speed on FHIR (Fast Healthcare Interoperability Resources)? You don’t want to look like you’re behind the times and unprepared for what’s next in healthcare, do you? Before your next cocktail party or networking event, arm yourself with the info you need on FHIR.
We want you to survive and thrive at your next networking event! Clearly, your focus should be on the bacon-wrapped shrimp, not on whether or not you are prepared for tech chat.
We designed this guide to give you exactly what you need to have a thoughtful, current conversation about FHIR at your next event. We start by explaining “what is FHIR?” Then we’ll present you the good stuff: main points from the most widely shared articles about FHIR in the past year. This represents the actual conversation about FHIR online in the past year. After each article, we clarify the “so what?” or why this actually matters.
You can read this straight through or just skim like a pro.
Section 1. Overview of Fast Healthcare Interoperability Resources
Want a good definition of FHIR? Want to understand how Healthcare is poised to take advantage of this new set of standards?
What is FHIR?
From Toehold Learning’s complete guide to FHIR. (Get a membership now!)
Put simply, FHIR is a standard way to structure and exchange data used by pieces of software in healthcare facilities.FHIR also structures the interoperability process by defining how programs transfer resources. To be clear, FHIR isn’t the data (or a type of data). Also, FHIR isn’t the software that exchanges the data. FHIR is instead the structures and language (semantics and coding) agreed upon by many in the healthcare industry that allows data to be transferred between software applications that house and use these data in a variety of ways.
So what does FHIR do? Nothing. It’s just a standard way to structure and exchange data. However, in its simplicity—in creating guidelines for structuring and transferring data written in languages all web-coders know—FHIR is potentially revolutionary. Central to FHIR apps is one critical function—the ability to search for and query or retrieve information from other systems—and that is a game-changer. FHIR may be more transformative than other emerging technologies because it unleashes the power of healthcare data by making it accessible across IT systems, EHRs, data silos, facilities, and even nations.
The FHIR standard allows for simplified, quick, and practical clinical information sharing between systems, by focusing on sharing small pieces of information, rather than entire documents. The structure of the data builds on logical and theoretical models consistent with previous standards to create coherent data-sharing resources—a method that is much more flexible than sharing entire documents. Because of its speed, granularity, and efficacy, FHIR is creating new opportunities for innovation across the healthcare industry.
Why does FHIR matter?
- HealthTech people are talking about it…a lot.
- FHIR is the best tool to improve interoperability.
- The industry is rallying around the FHIR standard.
- Many new and major companies are getting involved.
- Facilities need to prepare for the change to the FHIR standard.
Is Healthcare Ready for a FHIR Takeover?
However, while we can all agree that FHIR holds great promise for the future of interoperability, the industry shouldn’t jump ship too soon on the existing HL7 v2 and CDA standards.
That’s not to say that FHIR won’t win out for building new systems (because it will), but I do believe that FHIR will need to coexist with other standards for the foreseeable future. Reason being – there is no compelling economic argument to replace the billions of dollars worth of existing health IT systems that use other standards.
What I do expect to happen is that FHIR will serve as a translation layer. In fact, this was the first use we tackled at InterSystems – pulling V2 messages or CDA documents apart and storing them transiently as FHIR resources.
Using FHIR as a translation layer allows systems to take advantage of FHIR and its capabilities. The reverse transformation can take place where data is exported from the platform back to systems that still only understand the older standards.
So, what does this mean for healthcare organizations? They need to be thinking about a strategy to live in this hybrid standards environment by implementing solutions that can operate with a variety of standards.
So What: FHIR isn’t a forklift upgrade. You can start improving interoperability right away because it co-exists with existing systems.
FHIR is Coming of Age.
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 a growing number of use cases indicate FHIR has reached a tipping point as a mature standard for the electronic exchange of health information.
“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 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 UPMC. They have committed to working with the VA and standards community to implement the existing Argonaut Project implementation guides for the FHIR API.
So What: FHIR isn’t a baby anymore. We’re no longer wondering if it is going to take hold in the industry. It did.
Section 2. Major Players in FHIR
Get up to speed with the major players shaking up the healthcare industry with FHIR!
Apple Enters the EHR Game.
In the past, patients’ medical records were held in multiple locations, requiring patients to log into each care provider’s website and piece together the information manually. Apple worked with the healthcare community to take a consumer-friendly approach, creating Health Records based on FHIR (Fast Healthcare Interoperability Resources), a standard for transferring electronic medical records.
Now, consumers will have medical information from various institutions organized into one view covering allergies, conditions, immunizations, lab results, medications, procedures and vitals, and will receive notifications when their data is updated. Health Records data is encrypted and protected with the user’s iPhone passcode.
“Our goal is to help consumers live a better day. We’ve worked closely with the health community to create an experience everyone has wanted for years — to view medical records easily and securely right on your iPhone,” said Jeff Williams, Apple’s COO. “By empowering customers to see their overall health, we hope to help consumers better understand their health and help them lead healthier lives.”
So What? When the 94 million iPhones in America demand to use FHIR to exchange information, that’s what will happen. Period.
Technical Details of Apple’s Use of FHIR.
Health Records is going to be a new menu in the Health Data section of the Health app. You’ll be able to add any file to this menu as long as it’s a CDA file (Clinical Document Architecture). Some hospitals already email you those files or make them available on their website. But Apple wants to automate this process.
Johns Hopkins Medicine, Cedars-Sinai, Penn Medicine and others are already testing the feature with their patients. Health Records is based on FHIR (Fast Healthcare Interoperability Resources), a standard when it comes to data formats and APIs.
So it means that those hospitals and clinics will be able to push this data to your phone directly. You’ll receive a notification alerting you that you just received a new medical record. Data is encrypted on your phone and protected by your passcode.
So What? Patients will not have to sign into yet another portal when their test results are in. The results will be delivered to their phones. It’s one more battle won in the war against portal fatigue.
Google views FHIR as essential to AI in Healthcare.
Over the past 10 years, healthcare data has moved from being largely on paper to being almost completely digitized in electronic health records. But making sense of this data involves a few key challenges. First, there is no common data representation across vendors; each uses a different way to structure their data. Second, even sites that use the same vendor may differ significantly, for example, they typically use different codes for the same medication. Third, data can be spread over many tables, some containing encounters, some containing lab results, and yet others containing vital signs.
The Fast Healthcare Interoperability Resources (FHIR) standard addresses most of these challenges: it has a solid yet extensible data-model, is built on established Web standards, and is rapidly becoming the de-facto standard for both individual records and bulk-data access. But to enable large-scale machine learning, we needed a few additions: implementations in various programming languages, an efficient way to serialize large amounts of data to disk, and a representation that allows analyses of large datasets.
The point of this article is that Google is creating a whole new protocol buffer system to make FHIR work seamlessly for large-scale machine learning projects.
Over the past few years, as we’ve been partnering with academic medical centers to apply machine learning to de-identified medical records, it became clear that we needed to address the complexity of healthcare data head-on. Indeed, for machine learning to be effective on medical data, we need a holistic view of what happened to each patient over time. And as a bonus, we want a data representation that is directly applicable in a clinical setting.
So What? FHIR isn’t just some cool front-end tool to put your lab results onto your iPhone. GOOGLE is extending FHIR to do MASSIVE Machine Learning/AI projects with millions of patient records.
Cerner Views its EHR as a Platform for FHIR apps.
Basically, Cerner is creating the Apple App store for healthcare FHIR apps that embed directly into your EHR.
Cerner sees its EHR system emerging as a technology platform for a plethora of apps that leverage HL7’s emerging Fast Healthcare Interoperability Resources standard, enabling physicians to access these pluggable apps directly within their workflow to more easily visualize, interact and transmit health data.
“We’re really looking at this as Cerner is a platform versus a product solution,” says Zane Burke, president of Cerner. “We’ll know we’re there when you see a lot of apps on our platform.”
So What? Once upon a time, the EHR was the only solution. Now, though FHIR, the EHR is becoming an ecosystem of solutions.
Cerner’s 3rd Party FHIR apps drew an excited crowd at HIMSS2018.
What is SMART on FHIR? SMART is an acronym for “Suitable Medical Applications, Reusable Technologies.” SMART was born in 2010 from the Boston Children’s Hospital computational Health Informatics program and the Harvard Medical School Department of Biomedical Informatics. Using a $15M grant from the US government, they built a framework and platform allowing programmers and software developers to create applications embedded within EHRs that work across any FHIR-compatible system.
“For the first time ever, we’re able to, at scale, demonstrate how Cerner is working with third parties to take their technology and put it inside our EMR workflows so our providers can have choices and be able to use the applications that they choose to use,” Gilchrist told Healthcare IT News.
The technology that makes it possible is “SMART on FHIR.”
“SMART on FHIR” is very much a buzzword in the industry right now,” Gilchrist said. “It’s an open standard. It’s also very disruptive and innovative. It’s something everyone wants to talk about. We’ve had demos, we’ve had presentations, we’ve had interactions adhoc with more clients than I can count,” he said. “We’ve had conversations with other Cerner employees to show them what is possible so they can get back to their Cerner client and say you know there are some things that are possible, you know, we should check them out.”
So What? SMART on FHIR is basically like giving every healthcare tech developer an erector set to and saying: “what do you want to build into the EMR?”
Other EHR Vendors Line up behind FHIR, like DrChrono.
EHR vendor drchrono has announced that its electronic health record, practice management and revenue cycle products now support the Fast Healthcare Interoperability Resources specification.
With FHIR, drchrono said it is enabling 10 million patients to access to their healthcare information via the FHIR API through the company’s inpatient health record.
The new application programming interface is designed to support the Precision Medicine Sync for Science Initiative and fulfills one of the requirements of Meaningful Use Stage 3 to enable a patient health record API, the vendor said.
So what? FHIR is a straightforward way to meet the Meaningful Use Stage 3 Requirements.
Aneesh Chopra is on FHIR.
Now we are entering an upgrade cycle where we no longer have to wait years and years for the next piece of health information to move,” said Aneesh Chopra, the former U.S. chief technology officer and current president of CareJourney. “We are now moving to a more modern technology stack that will dramatically increase cycle time to get information into the hands of people who can make the most sense of it.”
That’s important because data transfer in healthcare today is messy. Two different healthcare organizations trying to exchange information typically require a custom configured data transfer. So, for example, there has been nothing quite like HTTP with the Internet, where everyone knows that when you type a certain combination of letters, a specific action will happen.
So What? FHIR reduces the cycle time for healthcare tech development. Given that healthcare IT seems to progress on a geological time frame, speeding things up will be good for everyone.
Section 3. General Conversations about Fast Healthcare Interoperability Resources
Want to be on top of the general conversations surrounding FHIR? These articles show the main ideas that have people talking and sharing about
Innovation by the numbers: CIOs say FHIR is promising, but Blockchain is Overhyped for Interoperability.
Innovation is something everyone in healthcare is after. But not everyone is approaching it the same way – and not everyone is able to prioritize it in the ways they’d prefer. That’s according to a new survey of CHIME member CIOs from Impact Advisors.
CIOs’ opinions of emerging technologies are especially interesting to note and offer some useful on-the-ground insights in an industry with no shortage of marketing hype.
FHIR and APIs were overwhelmingly seen as the tech with the most transformative potential over the next two years (50 percent of respondents), followed much further down the list by natural language processing (16.1 percent), cloud computing (14.3 percent) and machine learning (12.5 percent). Only 1.8 percent of CIOs surveyed cited blockchain as their top choice, with 48.2 percent listing it as the “most overhyped.”
So What? FHIR may not be as sexy as blockchain, but you can safely bet all your Bitcoin that there will be a lot more FHIR babies born in the next two years than Blockchain babies.
Are FHIR and Open APIs Ready for Prime Time?
https://www.healthcareit.com.au/article/fhir-and-open-apis-are-here-stay-are-they-ready-prime-timeHL7’s FHIR – it stands, of course, for Fast
Healthcare Interoperability Resources – has caught on faster than any other interoperability standards since it was first unveiled more than five years ago, thanks mostly to its ease of use compared to specs such as HL7 versions 2 and 3. [those are the previous standards used by HL7, the organization that brought you FHIR]
“It’s easy,” said Leftwich. “HL7 version 3 kind of fizzled because it broke under its own complexity – you practically had to have a PhD in it to build something simple with it. Not that it isn’t used some, but it was never going to take off like FHIR did.”
On the other hand, with FHIR, “there are hundreds of thousands of 20-somethings with web development skills who can get the idea of FHIR in a weekend,” he said. “There are FHIR hackathons where somebody walks in on a Saturday morning and doesn’t know anything about it, and on Sunday afternoon they’ve built a little app.”
Legions of app developers – however well-intentioned they are, however enthusiastic, however code-savvy – aren’t always as well-versed as they could be in the complicated details of medical data and clinical workflows. That’s led to a profusion of new technologies that often have limited utility for data exchange.
So What? It’s awesome that hundreds of thousands of new people can code HealthTech apps. But don’t worry about the millennial invasion of health apps, since you still need a lot of experience with clinical workflows to build something worth using.
Even your Genes Can’t Escape the All-Consuming FHIR!
Earlier this year, the Office of National Coordinator for Health Information Technology (ONC), in partnership with National Institutes of Health (NIH), announced the Sync for Genes pilots – an effort to strengthen genomic data sharing that is part of the Precision Medicine Initiative. As a result of this effort, a set of genomics specifications have been refined as part of the Health Level 7 (HL7®) Fast Healthcare Interoperability Resource (FHIR®) standard, as well as the results of the Sync for Genes pilot program. The updated clinical genomics resources and profiles from HL7 FHIR, along with the program results, are important steps towards enabling genomic data from next generation sequencing (NGS) laboratories to be shared in a consistent and interoperable manner with researchers, providers, and patients.
Rapid advances in the genomics field and the lack of standardized approaches to data collection, coding, and exchange have resulted in incompatible infrastructures and nomenclatures. A standards-based approach was needed to ensure that genetic data is interoperable among health information technology (health IT) systems and can be integrated easily with other clinical information.
The HL7 Clinical Genomics Work Group is taking advantage of the rapid advances made in the HL7 FHIR standard. As the first step towards integrating clinical genomics into clinical care, the Sync for Genes project leveraged the FHIR Genomics standard to support interoperable exchange of genomic data. The ongoing work and adoption by health IT developers through the All of Us Research Program will make future alignment of genomics information into point-of-care easier.
So What? FHIR is helping unlock the advances of genomic research. It will facilitate precision medicine.
Fun Fact: The GDPR Could Give Fast Healthcare Interoperability Resources a Boost!
Remember when every company who has your email address emailed you in the last week of May? They were preparing for the General Data Protection Regulation courtesy of the European Union.
René Spronk works for a Netherlands-based firm called Ringholm, a group of European experts in the field of messaging standards and systems integration in healthcare IT. He recently wrote a great online piece summarizing the impact of GDPR, highlighting from the regulation’s language some specific potential impacts:
Any application that creates, uses, or processes healthcare data is affected if that application is involved in any data processing scenario that requires explicit patient consent under the GDPR.
Spronk noted that whenever data needs to be exchanged, it would likely have to be enriched with metadata about things like consent, provenance and security labels. Here is one example: If the patient consented to sharing the data with the research community in general, then that consent would allow the receiver to re-disclose the data to other research organizations.
So if GDPR requires detailed consent management and security labels to follow the data, could FHIR help solve this problem? Spronk writes that FHIR Consent Directives tell data processors/holders what security labels to use on types/instances of data and related data.
GDPR also requires auditing capabilities, he wrote. Patients have the right to view their entries from the audit log of any data controller or data processor. These can be served as FHIR AuditEvent resources, he suggests.
So What? The architecture of FHIR is well suited to maintain compliance with EU law, not just Meaningful Use.
Section 4. The Devil’s Advocate
HealthTech news can often seem like all of the excitement with none of the downside of, ya know, the reality that interoperability is an incredibly difficult problem to solve. Indeed, FHIR is only one potential solution.
Not Everyone is Brimming with Unabashed Enthusiasm for FHIR. Here are some of the potential downsides.
There is a common misbelief that FHIR is going to provide a rapid path to robust interoperability between third-party applications and electronic health records (EHRs). Many believe FHIR will result in a standardized plug-and-play approach for rich data exchange. Just plug your application into FHIR and you are off and running!
This is flat out wrong for at least four reasons:
1. FHIR is not a standard, it is a “suggestion”. The biggest FHIR misconception is that it will be an industry standard. In theory, FHIR could be a standard. In practice, there are no enforcement mechanisms and EHR vendors (and others) have already implemented different versions of FHIR. It is clear that FHIR is NOT going to be a robust standard that is consistent across implementations.
2. EHR vendors are not implementing all available FHIR APIs. This creates another critical source of inconsistency. Developers who rely on FHIR for EHR integration must keep track of which EHRs have implemented which APIs. A robust API provided by one EHR may be completely absent in another.
3. EHR vendors are not consistently implementing the entire API. Even if two vendors implement the same FHIR API, they may not implement the entire specification for that particular API. One may have all data elements, while the next only includes a portion of the specification.
4. FHIR extensions undermine standardization. In principle, allowing developers to extend upon the basic FHIR specification can have advantages. In practice, this further undermines any attempt to create a standard. History shows that permissive models—like “z-segment” customization of HL7—opens the door to the wild west and results in divergence rather than convergence.
So What? The transformation of the healthcare system into a seamless flow electronic information won’t be as easy as we might want to think. Turns out, this is still going to be hard.
Talking Points for Fast Healthcare Interoperability Resources
Now you are ready to crush it with fantastic talking points for your next healthcare cocktail party! You’re ready to grab your canapé, a Heineken, and talk shop like a pro!
Let’s review the “So What?” takeaways from the most socially shared articles on FHIR in the past year.
- FHIR isn’t a forklift upgrade. You can start improving interoperability right away because it co-exists with existing systems.
- FHIR isn’t a baby anymore. We’re no longer wondering if it is going to take hold in the industry. It did.
- When the 94 million iPhones in America demand to use FHIR to exchange information, that’s what will happen. Period.
- Patients will not have to sign into yet another portal when their test results are in. The results will be delivered to their phones. It’s one more battle won in the war against portal fatigue.
- FHIR isn’t just some cool front-end tool to put your lab results onto your iPhone. Google is extending FHIR to do massive Machine Learning/AI projects with millions of patient records.
- Once upon a time, the EHR was the only solution. Now, though FHIR, the EHR is becoming an ecosystem of solutions.
- SMART on FHIR is basically like giving every healthcare tech developer an erector set to and saying: “what do you want to build into the EMR?”
- FHIR is a straightforward way to meet the Meaningful Use Stage 3 Requirements.
- FHIR reduces the cycle time for healthcare tech development. Given that healthcare IT seems to progress on a geological time frame, speeding things up will be good for everyone.
- FHIR may not be as sexy as blockchain, but you can safely bet all your Bitcoin that there will be a lot more FHIR babies born in the next two years than Blockchain babies.
- It’s awesome that hundreds of thousands of new people can code HealthTech apps. But don’t worry about the millennial invasion of health apps, since you still need a lot of experience with clinical workflows to build something worth using.
- FHIR is helping unlock the advances of genomic research. It will facilitate precision medicine.
- The architecture of FHIR is well suited to maintain compliance with EU law, not just Meaningful Use.
- The transformation of the healthcare system into a seamless flow electronic information won’t be as easy as we might want to think. Turns out, this is still going to be hard.