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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.

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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Epic Plans Meeting for Non-Epic Users on Data Sharing Capabilities

August 16, 2018
by Heather Landi
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Verona, Wis.-based Epic is inviting healthcare provider organizations that don’t use Epic’s electronic health record (EHR) to its “un-Users Group Meeting” at its Verona headquarters to learn how to exchange data with Epic.

The event, planned for September 26, will provide information to healthcare provider organizations about how to exchange charts with providers in their community who use Epic, even if providers use a different EHR— or no EHR at all.

According to Epic’s unUGM website, the event is for “executives and strategic leaders of provider organizations who want to learn and discuss how to exchange with providers in their community who use Epic.”

“Access to a patient’s information, regardless of where he or she has been seen, helps providers deliver the best patient care. The first Un-Users Group Meeting (unUGM) is another way we’re reaching out to the leaders of health systems using other EHRs—or even no EHRs—to help them get connected to the Epic users in their communities,” Dave Fuhrmann, Epic’s vice president of interoperability, said in a prepared statement.

According to the event agenda, topics of discussion include options for exchanging patient data with providers through Carequality, Care Everywhere, health information exchange (HIE) and Direct messaging, as well as patient-directed options, including MyChart, Share Everywhere, Lucy, and Blue Button.

There will also be discussion about interoperability success stories, using both non-Epic and Epic EHRs, and the current state of coordinated care in the U.S. and the use of existing tools to close care gaps, improve communication, and reduce costs.

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Amazon, Google, IBM and Other Tech Giants Pledge to Remove Barriers to Interoperability

August 14, 2018
by Heather Landi
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Six of the world's biggest technology companies, including Microsoft, Google, IBM and Amazon, made a joint pledge at the White House Monday to remove interoperability barriers and to make progress on adoption of health data standards.

The announced came during the Blue Button 2.0 Developer Conference in Washington, D.C. where Microsoft joined with Amazon, Google, IBM, Salesforce and Oracle to jointly commit to support healthcare interoperability by advancing healthcare standards such as HL7 (Health Level Seven International), FHIR (Fast Healthcare Interoperability Resources), and the Argonaut Project. They also pledged to remove interoperability barriers, particularly as it relates to the adoption of technologies enabled through the cloud and artificial intelligence (AI).

Dean Garfield, president and CEO of the Information Technology Industry Council, said in a statement, “Today’s announcement will be a catalyst to creating better health outcomes for patients at a lower cost. As transformative technologies like cloud computing and artificial intelligence continue to advance, it is important that we work towards creating partnerships that embrace open standards and interoperability.

“We commend the White House Office of American Innovation for their leadership in being a catalyst for moving health care beyond siloed systems and varied data standards. As well, we celebrate Amazon, Google, IBM, Microsoft, Oracle, and Salesforce for their commitment to helping to advance open healthcare standard. The opportunity to unleash greater innovation in health care is here and working together we can seize it,” Garfield said.

In a joint statement, the technology companies made a commitment to remove barriers to “frictionless data exchange,” noting that they share “the common quest to unlock the potential in healthcare data, to deliver better outcomes at lower costs.”

The commitment specifically states:

“In engaging in this dialogue, we start from these foundational assumptions: The frictionless exchange of healthcare data, with appropriate permissions and controls, will lead to better patient care, higher user satisfaction, and lower costs across the entire health ecosystem.

Healthcare data interoperability, to be successful, must account for the needs of all global stakeholders, empowering patients, healthcare providers, payers, app developers, device and pharmaceuticals manufacturers, employers, researchers, citizen scientists, and many others who will develop, test, refine, and scale the deployment of new tools and services.

Open standards, open specifications, and open source tools are essential to facilitate frictionless data exchange. This requires a variety of technical strategies and ongoing collaboration for the industry to converge and embrace emerging standards for healthcare data interoperability, such as HL7 FHIR and the Argonaut Project.

We understand that achieving frictionless health data exchange is an ongoing process, and we commit to actively engaging among open source and open standards communities for the development of healthcare standards, and conformity assessment to foster agility to account for the accelerated pace of innovation.”

Gregory J. Moore M.D., Ph.D., vice president of healthcare, Google Cloud, said in a statement, “We are pleased to join others in the technology and healthcare ecosystem in this joint commitment to remove barriers and create solutions for the adoption of technologies for healthcare data interoperability. This will enable the delivery of high quality patient care, higher user satisfaction, and lower costs across the entire healthcare ecosystem.”

Patients should have access to their data, said Mark Dudman, head of global product and AI development, IBM Watson Health, in a statement following the announced commitment. Patients also should have the flexibility to use products and services across different healthcare systems, with confidence that they all are working seamlessly for their care, he said. “We are proud to participate in this pledge and look forward to working with industry and the developer community to ensure appropriate access to data and the use of that data to support vibrant communities and solve health challenges for people everywhere.”

In a blog post, Josh Mandel, chief architect, Microsoft Healthcare, notes that interoperability is an overlapping set of technical and policy challenges, from data access to common data models to information exchange to workflow integration – and these challenges often pose a barrier to healthcare innovation.

Mandel, who previously worked at Google Life Sciences and on the research faculty at Boston Children’s Hospital where he worked on the SMART Health IT Platform, notes that support for the Meaningful Use Common Clinical Data Set grows and it is becoming easier to plug new tools into clinical workflows, analyze clinical histories, collect new data, and coordinate care.” Many of these technical capabilities have been available within small, tight-knit health systems for a long time – but developing these capabilities has required complex, custom engineering and ongoing maintenance and support. Driving toward open architecture makes adoption faster, easier and cheaper,” he wrote.

True interoperability in healthcare requires end-to end solutions, rather than independent pieces, which may not work together, Mandel wrote. “Transforming healthcare means working together with organizations across the ecosystem. Today’s joint interoperability statement reflects the feedback from our healthcare customers and partners, and together we will lay a technical foundation to support value-based care.”


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Industry Stakeholders Urge ONC to Move Forward on Information Blocking Rules

August 8, 2018
by Heather Landi
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In a strongly worded letter to National Coordinator Donald Rucker, M.D., several healthcare and health IT industry groups expressed frustration with the Office of the National Coordinator for Health IT’s lack of progress in publishing information blocking regulations, as required in the 21st Century Cures Act.

“It has been 601 days since the 21st Century Cures Act was signed into law. Every day that the administration delays implementation of these critical provisions places patients at risk of harm,” the letter states. Stakeholders including Health IT Now, Research!America, Oracle, the American Medical Informatics Association (AMIA), the American Academy of Family Physicians, Cambia Health Solutions and Claim Your Health Data Coalition signed the letter dated August 6.

In the letter, addressed to both Dr. Rucker and Daniel Levinson, inspector general of the Department of Health and Human Services (HHS), the stakeholder groups note that the 21st Century Cures Act, which was enacted in December 2016, requires the HHS Secretary to “issue regulations to prevent information blocking and to also identify reasonable and necessary activities that do not constitute information blocking.” Further, the law requires ONC to implement a standardized process for the public to submit reports on claims of health information technology products or developers of such products not being interoperable or resulting in information blocking and actions that result in information blocking. “The Office of the Inspector General (OIG) has enforcement authority over vendors and providers who are found to engage in information blocking,” the letter states.

The stakeholder groups also contend that “information blocking poses a significant risk to patient safety and greatly contributes to increased costs and waste in the health care system.”

According to reporting from Politico, during ONC’s 2nd Interoperability Forum this week in Washington, D.C., Rucker told the form audience that ONC is still working on the rule. The rule’s release has been delayed several times and is not expected to be released in September.

“Rucker emphasized Monday that his goal is to make protocols and standards that would let large amounts of health data flow easily between health providers, not just individual patient charts. He and other officials emphasized that ONC’s work is all being done within the confines of HIPAA,” the Politico article stated. Rucker also noted that properly defining which behaviors do and don’t constitute information blocking is “hard to sort out,” and the rule is a “work in progress,” Politico reported.

In a separate statement regarding ONC's delay in issuing an information blocking proposed rule, Douglas Fridsma, M.D., Ph.D., AMIA president and CEO, said, "Information blocking is the absence of interoperability, and there are numerous reasons why information may not flow as intended. Some of these reasons are technical, others for business or policy reasons. The socio-technical interoperability stack is complex and so too is the task of identifying which among its layers is responsible for information blocking. This rule must be critically calibrated to account for these layers, and it must be part of a larger conversation about how we will address other aspects of the socio-technical interpretability stack. Now is the time to initiate this broad conversation through release of the proposed information blocking rule."

In the letter, the industry groups also cautioned that “information blocking impedes provider access to the most current, accurate or complete information on their patients. As the administration proposes and implements new rules related to open APIs and interoperability in Medicare’s payment rules for hospitals and doctors, the lack of clear rules of the road needlessly creates uncertainty for vendors and providers alike.”

“We understand the nuance required but feel that it is past time for a proposal to be made,” the stakeholder groups wrote in the letter.

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