A Clinical Informaticist Shares Why FHIR Won’t Extinguish HL7, At Least Not in the Near-Term | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

A Clinical Informaticist Shares Why FHIR Won’t Extinguish HL7, At Least Not in the Near-Term

June 30, 2016
by Heather Landi
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Russell Leftwich, M.D., a clinical informaticist and an HL7 International board member, discusses the promise of FHIR in healthcare and the near-term “hybrid" world that healthcare organizations will be operating in.
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Within the healthcare industry, there is much discussion about the promise of Health Level Seven’s (HL7) Fast Healthcare Interoperability Resource (FHIR) standard and the role it will play in health IT’s future to improve interoperability and data exchange. Transitioning to FHIR, and enabling the use of web technology to manipulate data within the framework of FHIR, will transform healthcare organizations, essentially making it easier for providers to share health data, according to Russell Leftwich, M.D., adjunct assistant professor of biomedical informatics at Vanderbilt University and senior clinical advisor for interoperability at Cambridge, Mass.-based InterSystems, And, adoption of the FHIR standard will help bring healthcare forward, essentially catching up healthcare IT to the technology and domains used by Facebook, Google and Amazon.

However, Leftwich, who is an HL7 International board member, also says that for the foreseeable future, healthcare providers will need to translate between different standards—HL7 v2, HL7 v3 and Consolidated-Clinical Document Architecture (C-CDA) and FHIR—as there will be a need to transform back to earlier standards so that legacy systems can consume data.

Leftwich chairs the HIMSS Office of the National Coordinator for Health IT (ONC) Interoperability Standards Advisory Task Force and has previously served on the HIMSS Interoperability and Standards Committee. In addition, he is co-chair of the IHE USA Implementation Committee. He recently founded and is co-chair of the HL7 Learning Health Systems Workgroup and a past co-chair of the HL7 Patient Care Workgroup. Most recently he served as chief medical informatics officer for the State of Tennessee Office of eHealth Initiatives. Leftwich recently spoke with Healthcare Informatics Assistant Editor Heather Landi about the promise of FHIR in healthcare and the near-term “hybrid” environment that healthcare organizations will be operating in as the FHIR standard continues to be built out.

There is a lot of discussion about the promise of the FHIR standard to transform healthcare organizations. What role do you see FHIR playing in healthcare IT?

There’s no doubt, it will transform organizations. It allows the same type of information exchange that we’re used to in other domains and accessing information on multiple different servers, and that might be information for a particular individual that exists in different electronic health records (EHRs). FHIR will make it much easier to access all that information. However, the other reality is that, for the foreseeable future, we will live in a hybrid world of standards. There’s the existing standards, HL7 v2 and C-CDA, and they are not going away, not in the next 10 or 20 years. They will still be in use, and the HL7 version 2 standard is the most widely used standard, and it’s being used in countless systems out there and people aren’t going to simply replace those systems. They are going to continue to use those systems because that standard does what it does very well, as far as exchanging lab orders and lab results, between the EHR and the lab system. FHIR, as it’s built out over the next two or three years, will be a standard that can be used to translate between standards and allow those systems that are legacy systems using an older standard to still exchange information within the ecosystem of health information data. But there will still be a huge portion of the information ecosystem that use older standards, so having FHIR as one means of translating between different standards will be the reality of the future.


Advancements in Healthcare: Interoperability, Data Exchange, and More

Micky Tripathi, President and Chief Executive Officer of the Massachusetts eHealth Collaborative, is one of the most well-informed and well-respected healthcare IT leaders in the U.S. Tripathi has...

Russell Leftwich, M.D.

InterSystem has created a health information exchange (HIE) platform that’s enabled it to translate between HL7 v2 and C-CDA documents and FHIR, in both directions, so that people can use that as way of aggregating data about an individual and as a patient. If they turn that data into FHIR-based data, then it’s much easier to search and manipulate the data. I think that is one way FHIR will transform things at the point of care because once that data is in FHIR format, people will then use mobile devices to access that data, for things like decision support. FHIR is very adaptable to mobile devices such as smartphones and tablets, but also to mobile devices that are monitoring as well as medical devices, and the Internet of Things will be enabled by FHIR being the mechanism of interoperability. I think it will all feed into this hybrid ecosystem of different standards co-existing and FHIR will be the glue that ties all that together.

What is the latest progress on the FHIR standard?

We’re already starting to see FHIR-based apps and FHIR development going on. There was a panel at a meeting that I attended yesterday where people from four different organizations talked about how they are using FHIR in their organizations. In July, HL7 will have a two day event where different individuals and organizations will demonstrate what they’ve already done with FHIR within their organization. Right now, people have these apps that are enabled to use FHIR to access the data in that organization’s EHRs system but because these apps have been developed with earlier versions of FHIR, they won’t be easily carried across different organizations. Over the next year or two, as FHIR becomes stable enough and more developed, then apps will be developed. Organizations will have an app that you can get from an FHIR app store and actually be able to use that wherever your organization is.

Where does FHIR go from here?

That’s the future that’s coming very soon, the apps that people are using now are more proof of concept within the organizations. They’re using the apps and they are tremendously useful because they allow practitioners to do things and access the data in a way they couldn’t previously. And there’s work to be done with FHIR, as different parts of FHIR are not yet built out, particularly those parts that deal with very complex clinical data elements. The part of FHIR that deals with the more basic things like what’s the information around a patient or information around a particular condition, the way we specify a condition or a lab test, those things are fairly far along in FHIR. But more complicated concepts that relate to specialties and genetics and things like that are yet to be fully built out in FHIR. What needs to happen is that the entire FHIR community and the clinicians in particular need to get together, one data element at a time, and agree on a model, or how to represent that piece of data. You have to have that to really have interoperability across organizations. You have to agree that this is how we’re going to define this particular clinical data element or a particular diagnosis, but it’s not as complicated as some of these more sophisticated data elements.

So, FHIR will not eliminate the HL7 version 2 standard for now. What should health IT leaders be doing to ensure their information systems are prepared for this hybrid ecosystem of different standards?

Organizations certainly need to be planning their information architecture, if you will, for that future, which is probably not that far off, perhaps the next two to three years. I think they need to be strategic about the architecture they build out and the capabilities that are in the information architecture to adopt new standards like FHIR, but also to allow access to data that exists in these legacy systems that use older standards. And that’s because organizations can’t just go out and replace all these systems that are in use now. The average hospital in the US has something approaching 100 different IT systems within their hospital, and many of those systems are legacy systems that use older standards. But those standards work very well for what they are doing. They need to enable to make the best use of that data from these legacy systems in the future, so organizations need to have a strategy to bring these different types of data together.

One of the advantages of FHIR is that, in the past, to create an interface between two of those legacy systems using the existing standards like HL7 v2 and HL7 c-CDA, it took weeks to develop those interfaces. Those same interfaces leveraging FHIR can be developed in a matter of days, sometimes even hours, and having a strategy to adopt FHIR in a way that makes that data aggregation between old systems and new systems is going to be very important to organizations.

So it will be important for healthcare providers to be able to translate between these different standards to be successful, leveraging interoperability to achieve care coordination and value-based care, is that right?

Absolutely, with care coordination being the idea of having a virtual team that’s defined around an individual patient, and of those individuals some will be professionals and some family and community members. And that’s difficult to do right now because there’s no way to put data where it can be accessed by all of that virtual team. But with the FHIR standard, because of its adaptability with mobile devices and because all of the data could be put in a FHIR format, that will enable everybody on the virtual team to then access the data for that patient using a mobile device and using FHIR. And that’s the kind of thing that is already starting to happen within organizations. I would foresee in the next couple of years where it’ll start to happen more and more across organizations where there’s an HIE where they can access data with mobile devices and FHIR. And another angle to this that I think is very exciting is that each member of the virtual team will be able to have their own app, because app development with FHIR is relatively simple. And, in that sort of information ecosystem of the future, an app that’s developed for one place should be usable across the world.

So that’s a big part of the promise of FHIR, to create the universal platform that we have with Android and iOS in order to get an app from an app store that anybody can use on their device, anywhere, so that really is the promise of FHIR. And the idea that different individuals can have an app that suits their purposes instead of having to have a constant interface developed for a single EHR, which is prodigiously expensive. As an alternative, they can have an app that they got relatively inexpensively from an app store that will work wherever they are. I think a lot of people don’t understand that what’s been done with FHIR to this point is more proof of concept than it is proven out. What we’ll see in the next year or two with FHIR will be the realization of that promise of FHIR being a standard that can tie things together and give us access to all of the data about individuals as opposed to the data that’s in a single system.


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CommonWell Officials: Carequality Connection Now “Generally Available” for Members

November 16, 2018
by Rajiv Leventhal, Managing Editor
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CommonWell’s executive director said this latest step “breaks down another interoperability barrier”

Connection capabilities to the Carequality framework, by members of the CommonWell Health Alliance, are now “generally available,” according to officials who made an announcement today.

CommonWell, a trade association providing a vendor-neutral platform and interoperability services for its members, announced in August that it had started a limited roll-out of live bidirectional data sharing with an initial set of CommonWell members and providers and other Carequality Interoperability Framework adopters. This marked a key step in a collaborative effort to increase health IT connectivity across the country by enabling CommonWell subscribers to engage in health data exchange through directed queries with Carequality-enabled providers, and vice versa.

In just the first two weeks of a few CommonWell-enabled providers being connected, Jitin Asnaani, CommonWell Health Alliance executive director, said there were more than 4,000 documents bilaterally exchanged with Carequality-enabled providers.

Since then, by leveraging the technological infrastructure built by CommonWell service provider Change Healthcare, members Cerner and Greenway Health successfully completed a focused rollout of the connection with a handful of their provider clients, who have been exchanging data daily with Carequality-enabled providers, officials stated today.

Now, since the connection went live in July, officials noted  that CommonWell-enabled providers have bilaterally exchanged more than 200,000 documents with Carequality-enabled providers locally and nationwide.


Advancements in Healthcare: Interoperability, Data Exchange, and More

Micky Tripathi, President and Chief Executive Officer of the Massachusetts eHealth Collaborative, is one of the most well-informed and well-respected healthcare IT leaders in the U.S. Tripathi has...

“We are proud to break down yet another barrier to interoperability by making this much-anticipated connection available to our members and their clients,” Asnaani said in a statement today. “This increased connectivity will serve to empower providers with access to patient health data critical to their healthcare decision-making.”

In December 2016, CommonWell and Carequality, an initiative of The Sequoia Project, announced connectivity and collaboration efforts with the aim of providing additional health data sharing options for stakeholders. Officials said that the immediate focus of the work between Carequality and CommonWell would be on extending providers’ ability to request and retrieve medical records electronically from other providers. In the past two years, teams at both organizations have been working to establish that connectivity.

Together, CommonWell members and Carequality participants represent more than 90 percent of the acute EHR market and nearly 60 percent of the ambulatory EHR market. More than 15,000 hospitals, clinics, and other healthcare organizations have been actively deployed under the Carequality framework or CommonWell network.

Carequality is a national-level, consensus-built, common interoperability framework to enable exchange between and among health data sharing networks. It brings together electronic health record (EHR) vendors, record locator service (RLS) providers and other types of existing networks from the private sector and government, to determine technical and policy agreements to enable data to flow between and among networks and platforms.

CommonWell Health Alliance operates a health data sharing network that enables interoperability using a suite of services aiming to simplify cross-vendor nationwide data exchange. Services include patient ID management, advanced record location, and query/retrieve broker services, allowing a single query to retrieve multiple records for a patient from member systems.

Following the August announcement of the limited bi-directional data sharing capabilities, Micky Tripathi, Ph.D., president and CEO of the Massachusetts eHealth Collaborative said, “This is the ‘golden spike’ moment, connecting the two big railroads, like when AT&T and Verizon finally got connected. This is building that bridge.” Tripathi, who also directly observes and participates in conversations with Carequality and CommonWell, added, “It will take a while for all of the production sites and different vendors to get up and running. That will probably take a couple of years. But you have to have the bridge to connect them to begin.”

One key element in this progression is that currently, EHR giant Epic is not a member of CommonWell, despite other major EHR vendors pushing Epic in that direction. “Because sharing among Epic customers is already universal, when CommonWell connects to Carequality, the entire Epic base will become available, creating instant value for most areas of the country,” a recent KLAS report on interoperability stated.

Interestingly, Tripathi noted in August that once there is “general availability” of the data sharing services for all Carequality and CommonWell members, the competition factor will become less important. “It makes both networks more valuable,” Tripathi said at the time.

It appears as if that “general availability” time has now come. “Thanks to the CommonWell-Carequality connection, our patients can have access to their medical records regardless of the EHR a health care facility uses,” said David Callecod, president and CEO of Lafayette General Health, a Cerner client located in Lafayette, La. “When data is made readily available, providers can make diagnostic and treatment decisions more quickly, and patients can recover sooner. Better data means better communication with our patients and providers, better care and better outcomes. This is a very powerful tool!”

Officials also noted that with the connection officially in production, additional CommonWell members, including Brightree, Evident and MEDITECH, are in the process of subscribing to the connection and taking it live with their provider clients.

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Advancements in Healthcare: Interoperability, Data Exchange, and More

Tuesday, December 4, 2018 | 3:00 p.m. ET, 2:00 p.m. CT

Micky Tripathi, President and Chief Executive Officer of the Massachusetts eHealth Collaborative, is one of the most well-informed and well-respected healthcare IT leaders in the U.S. Tripathi has an inside look at the most significant interoperability trends that are happening nationwide and will discuss varying interoperability and data exchange efforts fit together in the bigger picture of U.S. healthcare.

Tripathi will also discuss the future of data exchange, advancements of standards such as FHIR, the reality of information blocking challenges, and more in this latest Healthcare Informatics webinar, which gives a high-level view on the many market forces that impacting nationwide interoperability.

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Epic Lowers App Orchard Program Fees, Introduces New Low-Cost Tier

November 1, 2018
by Heather Landi, Associate Editor
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Verona, Wis.-based Epic plans to lower program fees for health IT developers participating in its App Orchard program, and will launch a new entry-level program tier, called Nursery.

Epic announced the App Orchard updates at its App Orchard conference last week at its Verona headquarters, according to reporting from Politico published Oct. 26.

In an email statement, Brett Gann, App Orchard director, confirmed the company is reducing and simplifying the costs associated with participating in the app developer program. The three tiers of the program will see program fee reductions ranging from 33 to 80 percent as part of the update, Gann said.

Epic launched its App Orchard in 2017 as an online marketplace for third-party developers with 13 applications.

To date, more than 350 companies in the healthcare industry participate in Epic’s app developer program, where they have access to hundreds of application programming interfaces (APIs), documentation, testing tools, individual technical support, training, conferences, and integration with the Epic community, Gann said,

Gann also said the program updates announced last week at the annual App Orchard Conference in Verona will “engage a broader community of developers and increase access to APIs through simplified and reduced costs.”

The updates will help drive healthcare innovation as interested developers have the opportunity to build on top of Epic’s health record platform, using emerging industry standards such as FHIR (Fast Healthcare Interoperability Resources), Gann said.

Epic also announced a new program tier, Nursery, that will enable early-stage startups to enroll in the app developer program to access Epic’s public API documentation, tutorials, and sandboxes. Early-stage startups also will have access to FHIR, SMART on FHIR, and CDS Hooks, Gann said.

Enrolling in the Nursery program tier will cost participants $100 per year, Gann said, and when a company is prepared to go to market with its product, it may graduate to one of the other three tiers.

Nursery members will have access to Epic’s FHIR sandboxes, classroom and online learning opportunities, and the ability to engage with the online community of Epic, health system, and vendor developers and experts.

In addition to the program fee reductions, as part of the update, Epic will offer new program benefits to participants in the other three tiers, such as additional training opportunities, developer events, support services, sandboxes, and program accounts.

Gann also said Epic has simplified the pricing model for API-based integrations, eliminating the minimum fees, and reducing the cap. “It’s our expectation these updates will be a price reduction for nearly all program members,” he said.

Some developers, particularly smaller developers, have complained in the past that the fees to participate in the vendor app store are too steep.

Earlier this year, Politico reported the experiences of Rick Freeman, CEO of Interopion. Freeman told Politico that a family planning questionnaire app he developed for HHS’s Office of Population Health could have cost him up to $750,000 to run on Epic or Cerner for a year.

As reported by Politico in its October 26 report, in response to the program updates, Freeman said he is “very happy with the changes.”

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