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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