Top Ten Tech Trends 2017: Slow FHIR: Will a Much-Hyped Standard Turbo-Charge Interoperability—Or Maybe Not Quite? | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Top Ten Tech Trends 2017: Slow FHIR: Will a Much-Hyped Standard Turbo-Charge Interoperability—Or Maybe Not Quite?

March 21, 2017
by Mark Hagland
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Industry leaders see a landscape filled with complexity, when it comes to FHIR’s potential for facilitating rapid progress towards healthcare IT interoperability

Industry leaders see a landscape filled with complexity, when it comes to FHIR’s potential for facilitating rapid progress towards healthcare IT interoperability

Depending on whom you talk to, the U.S. healthcare system is either A) “totally on fire” with FHIR (the Fast Healthcare Interoperability Resources draft standard); B) awash with overblown hype on the potential for FHIR to transform the development of APIs (application program interfaces) in healthcare; or C) somewhere in between, with a mix of signals out in the landscape around the FHIR standard and around its potential to profoundly alter the course of the evolution of interoperability going forward.

And whether you tend towards A, B, or C, the reality is that a lot of developments have been advancing lately. For example, on Feb. 1, as Healthcare Informatics Senior Contributing Editor David Raths reported, “Standards organization HL7 has announced a collaboration agreement with the Healthcare Services Platform Consortium (HSPC), a provider-led nonprofit group working toward the development of an open ecosystem of interoperable applications, content, and service-oriented architecture (SOA) services.” As Raths reported, “HSPC’s vision is that, similar to iOS and Android, it will support a marketplace model for plug-and-play healthcare applications leveraging the work at Intermountain Healthcare, LSU Health, the VA VistA Evolution initiative, and others. The HSPC marketplace would support common services and models that providers and vendors could use to shorten development lifecycles.”

Meanwhile, very importantly, as Managing Editor Rajiv Leventhal reported on Dec. 14, the CommonWell Alliance and CareQuality, a division of The Sequoia Project, which is devoted to healthcare IT interoperability, announced on that date a set of agreements involving pushing forward into interoperability.  Among other elements, CommonWell will become a CareQuality implementer on behalf of its members and their clients, enabling CommonWell subscribers to engage in health information exchange through directed queries with any CareQuality participant, while CommonWell and the Sequoia Project, CareQuality’s umbrella organization, plan to collaborate on connectivity efforts going forward.

So things are moving forward now, on a variety of levels. But what about the larger promise of FHIR in terms of U.S. healthcare eventually reaching true interoperability? There is a broad spectrum of views on that. “My view is that I welcome FHIR as a development; I think that anything that moves us away from the traditional handcrafted approach around APIs is helpful,” says Dave Levin, M.D., the former CIO of the Cleveland Clinic Health System and a partner in Amati Health, a Suffolk, Va.-based consulting firm. “I think it’s broadened the discussion, and I think the people involved have good intentions. I welcome that. I think there are some challenges, though,” Levin says. “I hear a lot of ‘happytalk,’ that this is the silver bullet that will fix everything,” and that is simply not realistic, he says. “I worry that expectations are too high. FHIR is a standard like others—a starting point, not a specification.”


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What Does Geisinger’s Trial by FHIR Mean?

In that “starting point” assessment, Levin is joined by Alistair Erskine, M.D., CMIO of the Danville, Pa.-based Geisinger Health System. The experience that Erskine and his colleagues had recently with developing and then attempting to commercialize a FHIR-compliant app, demonstrates both the upside and the downside of the current FHIR-facilitated landscape, he says. Erskine and his colleagues invested time, effort, and funding into the creation of a rheumatology application. “We proved that we could use it on several different platforms,” he reports. “We tried to commercialize it, but got nowhere. There were two key problems. One, the various EHRs [electronic health records] weren’t really ready for a production-based mechanism. There was a lot of work the client had to do on their end to make it work; it wasn’t plug-and-play. Instead,” he says, “it was, build to plug, and do a lot of work to play. And while the app did something useful and helped us to take care of rheumatology arthritis patients, the colors, the buttons, and the feel weren’t harmonious with existing EMRs. So the informaticians and clinicians weren’t comfortable with having to teach end-users to use this.”

Alistair Erskine, M.D.

Erskine says that Geisinger’s experience with the rheumatology-focused app points to a broad weakness in the current development landscape. “How do you take all these disparate apps and make them work with the natural user interfaces that end-users are used to?” he asks. “Unlike an app on an iPhone, each download of an app using SMART on FHIR requires BA [business associate] agreements, a whole series of architectural reviews with a client, and a whole series of contractual arrangements. So there really was a missing app store where you could say everything in that app store is already vetted, is safe, is free from hacking, is something that I can trust.” And while a small number of the biggest EHR vendors, including Cerner Corporation, McKesson Corporation, and Epic Health Systems, have built platforms on which developers can create FHIR-compliant apps, there is not yet an easy pathway for the development of apps by organizations like Geisinger Health, that will readily be accepted by practicing physicians and other clinicians.

As a result of that reality on the ground, Erskine says, “We found that the end-user experience tends to be different from EHR to EHR, so we said, let’s let the EHR vendor control the graphical user interface; we can use FHIR to augment the data sitting in the EHR. So if I use my big data platform to identify patients with kidney disease who should have that marked on their problem list, I can alert my EMR to alert the end-user physician.” It’s not an ideal situation, he concedes. “It would have been nice, if I’m a rheumatologist, to go to this pre-approved app store and download a few apps that would work for me as a clinician. That would have been nice if that had been feasible. So the reluctance of the vendors to have something user-ready and the contractual issues, etc., those are all reasons it hasn’t flourished yet.”

Progress on Interoperability is in the Eye of the Beholder

Industry leaders and experts agree that the landscape around FHIR and interoperability is one of tremendous complexity, with no black-and-white, only shades of gray. No one is calling progress so far in that area a “10,” but neither is anyone calling it a “0.” Among those feeling mildly optimistic is Doug Fridsma, M.D., Ph.D., president and CEO of the Bethesda, Md.-based American Medical Informatics Association (AMIA). “The first thing you have to ask,” he says, “is, what do you want to accomplish? What is the task, and what do you want to do? We’ll always be chasing after interoperability; we’ll never have perfect interoperability, because there will always be new things; it will be a continuous process.”

Doug Fridsma, M.D., Ph.D.

Fridsma says that “One of the things about FHIR is that it has a much more nuanced approach to those things that are ready to be done, and those that aren’t yet. There are pretty mature uses, that can be deployed. One of the nice things about FHIR is that it matches better the progression we need to take to match true interoperability. A second good thing about FHIR is that because it’s about exchange in use, vendors, developers, and implementers see it as a value way to get their work accomplished, so we have a much better chance of FHIR serving as the foundation for these solutions.”

In the end, industry leaders agree, FHIR’s role as a facilitator of interoperability will continue to advance—neither as rapidly and spectacularly as many would like, but at the same time, with deliberation, and through gradual, trial-and-error-based progress, as the healthcare industry works out not only the technical aspects of interoperability, but much more so the policy, business, process, and end-user capability aspects of a phenomenon that is so crucial to the broader advancement of U.S. healthcare.

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HL7 Model Identifies Clinical Genomics Workflows, Use Cases

January 16, 2019
by David Raths, Contributing Editor
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Domain Analysis Model covers pre-implantation genetic diagnosis, whole-exome sequencing, RNA sequencing and proteomics

HL7’s Clinical Genomics Work Group has published an HL7 Domain Analysis Model (DAM) to identify common workflows and use cases to facilitate scalable and interoperable data standards for the breadth of clinical genomics scenarios.

The Domain Analysis Model (DAM), which has underdone a rigorous ISO/ANSI-compatible balloting process, covers a myriad of use cases, including emerging ones such as pre-implantation genetic diagnosis, whole-exome sequencing, RNA sequencing and proteomics.

The effort “builds on the DAM Clinical Sequencing work that is already being used to design precision medicine workflows at hospitals across the country,” said Gil Alterovitz, Ph.D., an HL7 Clinical Genomics Work Group co-chair, in a prepared statement. He also serves as a Harvard professor with the Computational Health Informatics Program/Boston Children’s Hospital.

The Clinical Sequencing DAM fueled the design of FHIR Genomics, the subset of HL7’s FHIR standard designed to communicate clinical genomic information. “By extending to broader domains, it can serve as a standard going forward to aid in the design of workflows, exchange formats as well as other areas,” Alterovitz added,

The document presents narrative context and workflow diagrams to guide readers through the stages of each use case and details steps involving the various stakeholders such as patients, health care providers, laboratories and geneticists. This contextual knowledge aids in the development and implementation of software designed to interpret and communicate the relevant results in a clinical computer system, especially a patient's electronic health record.

The HL7 Clinical Genomics Work Group developed several new applications and refinements in the Domain Analysis Model beyond its original scope of clinical sequencing. One notable addition is the analysis of the common workflows for pre-implantation genetic diagnosis (PGD). For those undergoing in-vitro fertilization, advanced pre-implantation genetic screening has become increasingly popular as it avoids the implantation of embryos carrying chromosomal aneuploidies, a common cause of birth defects. Implementers can follow the workflow diagram and see the context for each transfer of information, including the types of tests performed such as blastocyst biopsy and embryo vitrification.

As the clinical utility of proteomics (detecting, quantifying and characterizing proteins) and RNA-sequencing increases, the DAM also outlines clinical and laboratory workflows to capitalize on these emerging technologies.

HL7 notes that future challenges arise from uncertainty about the specific storage location of genomic data, such as a Genomics Archive and Computer/Communication System (GACS), as well as the structure of a patient’s genomic and other omics data for access on demand, both by clinicians and laboratories. Best practices in handling such considerations are being formulated within HL7 and include international input from across the spectrum of stakeholders. In parallel, the HL7 Clinical Genomics Work Group has been preparing an implementation guide for clinical genomics around many of these use cases, to be leveraged alongside the newly published HL7 FHIR Release 4 standard.


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ONC Releases Interoperability Standards Advisory Reference 2019

January 15, 2019
by Heather Landi, Associate Editor
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The Office of the National Coordinator for Health IT (ONC) has released the 2019 Interoperability Standards Advisory (ISA) Reference Edition, which serves as a “snapshot” view of the ISA.

The 2019 Interoperability Standards Advisory represents ONC’s current assessment of the heath IT standards landscape. According to ONC, this static version of the ISA won’t change throughout the year, while the web version is updated on a regular basis. The ISA contains numerous standards and implementation specifications to meet interoperability needs in healthcare and serves as an open and transparent resource for the industry.

The Interoperability Standards Advisory (ISA) process represents the model by which ONC coordinates the identification, assessment, and public awareness of interoperability standards and implementation specifications that can be used by the healthcare industry to address specific interoperability needs including, but not limited to, interoperability for clinical, public health, research and administrative purposes. ONC encourages all stakeholders to implement and use the standards and implementation specifications identified in the ISA as applicable to the specific interoperability needs they seek to address. Furthermore, ONC encourages further pilot testing and industry experience to be sought with respect to standards and implementation specifications identified as “emerging” in the ISA.

The newest ISA reference edition includes improvements made based on comments provided by industry stakeholder during the public comment period, which ended Oct. 1, according to a blog post written by Steven Posnack, executive director of ONC’s Office of Technology, Chris Muir, standards division director, Office of Technology, and Brett Andriesen, ONC project officer. ONC received 74 comments on the ISA this year, resulting in nearly 400 individual recommendations for revisions.

According to the blog post, the ISA contains “a variety of standards and implementation specifications curated by developers, standards gurus, and other stakeholders to meet interoperability needs (a term we use in the ISA to represent the purpose for use of standards or implementation specifications – similar to a use case) in healthcare.”

“The ISA itself is a dynamic document and is updated throughout the year, reflecting a number of substantive and structural updates based on ongoing dialogue, discussion, and feedback,” Posnack, Muir and Andriesen wrote.

The latest changes to the reference manual include RSS feed functionality to enable users to track ISA revisions in real-time; shifting structure from lettered sub-sections to a simple alphabetized list; and revising many of the interoperability need titles to better reflect their uses and align with overall ISA bets practices. According to the ONC blog post, the updates also include several new interoperability needs, including representing relationship between patient and another person; several electronic prescribing-related interoperability needs, such as prescribing weight-based dosing and request for refills; and operating rules for claims, enrollment and premium payments.

The latest changes also include more granular updates such as added standards, updated characteristics and additional information about interoperability needs.

The ONC officials wrote that the ISA should be considered as an open and transparent resource for industry and reflects the latest thinking around standards development with an eye toward nationwide interoperability.

The ISA traditionally has reflected recommendations from the Health IT Advisory Committee and its predecessors the HIT Policy Committee and HIT Standards Committee and includes an educational section that helps decode key interoperability terminology.


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ONC Report: Health IT Progress Stifled by Technical, Financial Barriers

January 15, 2019
by Heather Landi, Associate Editor
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While progress has been made in the adoption of health IT across the U.S. healthcare industry, significant interoperability hurdles remain, including technical, financial and trust barriers, according to a report from the Office of the National Coordinator for Health Information Technology (ONC).

Currently, the potential value of health information captured in certified health IT is often limited by a lack of accessibility across systems and across different end users, the ONC report stated.

The annual report from the U.S. Department of Health and Human Services (HHS) and ONC to Congress highlights nationwide health IT infrastructure progress and the use of health data to improve healthcare delivery throughout the U.S.

The report, “2018 Report to Congress: Annual Update on the Adoption of a Nationwide System for the Electronic Use and Exchange of Health Information,” also reflects progress on the implementaions of the Federal Health IT Strategic Plan 2015-202 and the Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap.

In the report, ONC notes that most hospitals and health care providers have a digital footprint. As of 2015, 96 percent of non-federal acute care hospitals and 78 percent of office-based physicians adopted certified health IT. The increase in health IT adoption means most Americans receiving health care services now have their health data recorded electronically.

However, hurdles to progress still remain. For example, ONC notes that many certified health IT products lack capabilities that allow for greater innovation in how health information can be securely accessed and easily shared with appropriate members of the care team. “Such innovation is more common in other industries. Also, lack of transparent expectations for data sharing and burdensome experiences for health care providers limit the return on investment for health care providers and the value patients are able to gain from using certified health IT,” the report authors wrote.

While health information is increasingly recorded in a digital format, rather than paper, this information is not always accessible across systems and by all end users—such as patients, health care providers and payers, the report authors note. Patients often lack access to their own health information, healthcare providers often lack access to patient data at the point of care, particularly when multiple healthcare providers maintain different pieces of data, own different systems or use health IT solutions purchased form different developers, and payers often lack access to clinical data on groups of covered individuals to assess the value of services provided by their customers.

Currently, patients electronically access their health information through patient portals that prevent them from easily pulling from multiple sources or health care providers. Patient access to their electronic health information also requires repeated use of logins and manual data updates, according to the report. For healthcare providers and payers, interoperable access and exchange of health records is focused on accessing one record at a time. “Without the capability to access multiple records across a population of patients, healthcare providers and payers will not benefit from the value of using modern computing solutions—such as machine learning and artificial intelligence—to inform care decisions and identify trends,” the report authors wrote.

Looking at the future state, the report authors contend that certified health IT includes important upgrades to support interoperability and improve user experience. Noting ONC’s most recent 2015 edition of certification criteria and standards, these upgraded capabilities will show as hospitals and healthcare provider practices upgrade their technology to the 2015 edition, the report authors state.

“As HHS implements the provisions in the Cures Act, we look forward to continued engagement between government and industry on health IT matters and on the role health IT can play to increase competition in healthcare markets,” the report authors wrote, noting that one particular focus will be open APIs (application programming interfaces). The use of open APIs will support patients’ ability to have more access to information electronically through, for example, smartphones and mobile applications, and will allow payers to receive necessary and appropriate information on a group of members without having to access one record at a time.

Healthcare industry stakeholders have indicated that many barriers to interoperable access to health information remain, including technical, financial, trust and business practice barriers. “In addition, burden arising from quality reporting, documentation, administrative, and billing requirements that prescribe how health IT systems are designed also hamper the innovative usability of health IT,” the report authors wrote.

The report also outlines actions that HHS is taking to address these issues. Federal agencies, states, and industry have taken steps to address technical, trust, and financial challenges to interoperable health information access, exchange, and use for patients, health care providers, and payers (including insurers). HHS aims to build on these successes through the ONC Health IT Certification Program, HHS rulemaking, health IT innovation projects, and health IT coordination, the report authors wrote.

In accordance with the Cures Act, HHS is actively leading and coordinating a number of key programs and projects, including “continued work to deter and penalize poor business practices that lead to information blocking,” for example.

The report also calls out HHS’ efforts to develop a Trusted Exchange Framework and a Common Agreement (TEFCA) to support enabling trusted health information exchange. “Additional actions to meet statutory requirements within the Cures Act including supporting patient access to personal health information, reducing clinician burden, and engaging health and health IT stakeholders to promote market-based solutions,” the report authors wrote.

Moving forward, collaboration and innovation are critical to the continued progress on the nationwide health IT infrastructure. To that end, the HHS report authors recommend that the agency, and the health IT community overall, focus on a number of key steps to accelerate progress. Namely, health IT stakeholders should focus on improving interoperability and upgrading technical capabilities of health IT, so patients can securely access, aggregate and move their health information using their smartphones, or other devices, and healthcare providers can easily send, receive and analyze patient data.

The health IT community also should focus on increasing transparency in data sharing practices and strengthen technical capabilities of health IT, so payers can access population-level clinical data to promote economic transparency and operational efficiency, which helps to lower the cost of care and administrative costs, the report authors note.

Health IT developers and industry stakeholders also needs to prioritize improving health IT and reducing documentation burden, time inefficiencies and hassle for healthcare providers so clinicians and physicians can focus on their patients rather than their computers.


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