Last year, Healthcare Informatics made the HL7 draft standard Fast Healthcare Interoperability Resources (FHIR) one of our Top 10 Tech Trends to watch.
This year, interoperability is the first topic of conversation wherever CIOs and CMIOs gather, and FHIR is now at the center of the discussion. Standards developers may be used to people ignoring their work, but suddenly they are in the spotlight. At this year’s American Medical Informatics Association conference in Washington, D.C., the sessions on FHIR and public application programming interfaces (APIs) were standing-room-only.
With so many provider organizations struggling with Stage 2 of meaningful use, observers are wondering what role the Office of the National Coordinator for Health IT (ONC) will play in standards development and promotion. Some have suggested that ONC “declare victory” with meaningful use and move on or narrow the focus of Stage 3 to interoperability issues alone.
One person at the center of the “FHIR storm” in terms of what the draft standard could mean to policy development and regulation is Micky Tripathi, Ph.D., president and CEO of the Massachusetts eHealth Collaborative (MAeHC). He co-chaired the ONC’s JASON Report Task Force and chairs the Policy Committee’s Interoperability and Health Information Exchange Workgroup as it makes recommendations on ONC’s 10-year interoperability roadmap. MAeHC is taking the project management role on HL7’s Argonaut Project to accelerate FHIR’s development and adoption.
Tripathi says that ONC might be at a turning point. “We have to recognize, as we turn the corner from Stage 2 to Stage 3 on the interoperability side, that we are starting to see some developments happening in the private sector, and it raises the question of whether the federal government needs to play a role anymore,” he says. “Are we at a point where the market could actually pick it up and play the lead role? There is a strong sense in the industry that we are at that point.”
Micky Tripathi, Ph.D.
There’s one key question the Interoperability Work Group is posing to ONC about the roadmap under development, and it gets to a larger issue about the future role of ONC itself in interoperability. “Is it just going to describe what is happening in the marketplace?” Tripathi asks, “Or if it is going to be prescriptive, with what authority and incentives are you going to be prescriptive? We have to understand the role ONC imagines playing.”
He stresses that it is valuable to create a roadmap and ONC is the right organization to set goals, but he added that any time you start talking about 10 years, things tend to get highly speculative. “In our workgroup, we’ve said let’s just talk about the next three years. Beyond that, it is anyone’s guess.”
HL7 CEO Charles Jaffe, M.D., Ph.D., agrees with Tripathi that planning for 10 years out is too difficult, beyond setting an ultimate goal. He stresses the significance of the Argonaut Project, in which several leading EHR vendors, including Epic and Cerner, and some integrated health systems such as Intermountain Health, have put their financial support behind FHIR development. “I think you can tell from the landscape that the private sector has taken the initiative to develop some of its own pathways to interoperability,” he says. “And I think even for the most optimistic of us, it will not be a big bang, where one day we didn't have interoperability and the next day we did. It will come in stutter steps and great leaps. And I think some of the things going on now are great leaps.”
Charles Jaffe, M.D., Ph.D.
Speaking at a November webinar panel discussion on interoperability issues, John Halamka, M.D., CIO at Beth Israel Deaconess Medical Center and co-chair of the HIT Standards Committee, said the industry needs more than standards; it needs an ecosystem and a coordinated architecture. “It’s not sufficient that every EHR simply have an API,” he said. “In the JASON Task Force report, they propose a data-sharing network or arrangement with the notion of a trust fabric determining who can get access to data.”
Halamka explained that consolidated clinical document architecture (CCDA) and Direct messages send packages of data, but that just pushing data is insufficient. It is difficult to parse CCDA and write back to data structures. The industry needs to be able to pull discrete data and write back, and an API approach allows that. The other key, he said, is to avoid a single top-down approach. If we create a federation of loosely coupled data sources, APIs would allow them to be linked, he said. Entrepreneurs could create new apps and modules. Patients could download data form everywhere they are treated. “Epic has created its Care Everywhere network. Great—use the ecosystem as a way to leverage what we already have and knit them together,” he said. “Federated and coordinated and distributed.”
In the same panel discussion, Arien Malec, vice president for data platform and acquisition tools at Relay Health, called the interest in FHIR unprecedented. “I don’t think I’ve seen anything that has received this much attention from folks at HL7 in the last decade,” he said.
David Minch, president and board chair of the nonprofit California Association of HIEs (CAHIE), recommends moving from second-generation data exchange protocols and content packaging, which have reinforced “walled garden” approaches, toward open APIs, simple content packaging, and Internet-appropriate protocols (FHIR). He also suggests that rather than focusing on policy levers that establish governance mechanisms for health information exchange, ONC should support the development of technical standards and especially concise and explicit reference implementations of the standards.
Minch says he knows how strongly National Coordinator for Health IT Karen DeSalvo, M.D., feels about the importance of interoperability, “But if we continue business as usual, this whole roadmap exercise is just one more self-flagellation about moving things forward, even though we are staying in place,” he says. “She can make a tremendous impact on ONC in terms of changing its trajectory, but it is going to take standing up to the vendor community. Just a little bit of backbone goes a long way.”
Tripathi says some people have expressed concerns that the JASON Report Task Force was suggesting dropping everything else going on to focus on something that hasn’t even been tested in the marketplace yet. “That is not what we said. It is an evolving market, with lots of ways of doing things, and they will persist and people should keep doing those,” he says. “But the current approaches are structurally limited, and they are not going to get us to the next level. We have got to work toward getting there.”