FHIR Interoperability Basics: 4 Things to Know

February 23, 2022 - As health data interoperability becomes an increasingly pressing concern for providers, developers and vendors are paying a great deal more attention to the data standards that will enable seamless, on-demand information exchange.

The Fast Healthcare Interoperability Resource, commonly known as FHIR, quickly became one of the most popular protocols for joining together disparate systems and continues to hold great promise for developing an application-based approach to interoperability and health information exchange.

But what is FHIR, and how is it being used to further health data exchange?

In this article, HealthITAnalytics breaks down the basics of one of the critical standards enabling efficient and secure interoperability.

What is FHIR?                                

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The Fast Healthcare Interoperability Resource is a draft data standard developed and nurtured by HL7 International.  FHIR was created with the complexity of healthcare data in mind and takes a modern, internet-based approach to connect different discrete elements.

"The philosophy behind FHIR is to build a base set of resources that, either by themselves or when combined, satisfy the majority of common use cases. FHIR resources aim to define the information contents and structure for the core information set that is shared by most implementations," HL7 states on its website.

Data elements, or "resources," each have a tag that acts as a unique identifier, just like the URL of a web page.

"When you order something on Amazon, for example, look at your browser line," explained Micky Tripathi, the national coordinator for health IT at the Department of Health and Human Services and former CEO of the Massachusetts eHealth Collaborative, to HealthITAnalytics. "If you're logged in and you click on something, what you’ll see is a URL that says 'https' and then this huge string of nonsense. That's a query-retrieve system that's generated in your browser and sent to Amazon, and then Amazon immediately returns the results securely."

On the internet, users across the world can access the same URL and complete the same tasks using any standard browser running on any web-enabled device, whether it’s a smartphone, desktop, or tablet running a Windows, Apple, Android, or Linux operating system.

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FHIR hopes to do the same thing: allow developers to build standardized "browser" applications that will enable access to data no matter what EHR "operating system" underpins the user's infrastructure.

The key to this is the resource. An FHIR resource can be an individual packet of information that includes metadata, text, or particular data elements but can also be bundled into collections that create clinical documents, similar to the Consolidated Clinical Document Architecture (C-CDA), but much more flexible.

"FHIR resources can be used to build documents that represent a composition: a set of coherent information that is a statement of healthcare information, particularly including clinical observations and services," HL7 states. "A document is an immutable set of resources with a fixed presentation that is authored and/or attested by humans, organizations and devices."

By creating an accessible and standard URL for these information bundles instead of just passing individual documents back and forth between systems, several applications can point to the same version of the same data every time.

What makes FHIR different from other attempts at improving interoperability?

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At the moment, most health information exchange and data interoperability is based on documents. Whether faxed, emailed, or sent electronically, providers typically have to choose a set of data to transmit and generate a message containing only that data.

While this approach does help organizations successfully communicate, it can be too limiting for meaningful care coordination, decision making, or data analytics.

For example, the C-CDA is a standardized document format that contains a great deal of critical information, but it is like a PDF — the data is relatively static, and it takes a special effort to extract the information and make it usable in any other format.

"The exchange of these documents has a certain value, because…whole documents are really important in clinical care," said Tripathi.

While having complete information is important, document-based exchange doesn't allow a provider to delve into the context of the data received.

"If you just send me some lab results or a list of allergies, that's great," he said. "I need those things, but you haven’t told me the story of the patient, and that's really important for a clinician to understand. Document exchange is important, but so is that data-level exchange. Health information exchange based entirely on C-CDA XML documents doesn't allow you to access information at a data level as well."

Using standardized application programming interface (API) standards, FHIR allows developers to create apps that transcend this document-based environment. Applications can be plugged into a basic EHR operating system and feed information directly into the provider workflow, avoiding pitfalls of document-based exchange, which often requires providers to access data separately.

"[FHIR] is…fundamentally well-designed," David McCallie, MD, Trusted Exchange Framework and Common Agreement Task Force member and former senior vice president of informatics at Cerner Corp. told HealthITAnalytics. "It's based on the same technologies that power the internet. We've had several decades of experience, now, in figuring out how to make the internet scale, and many of those good ideas are encapsulated in the core design of FHIR."

"That's a much better starting point than some of the previous standards used in healthcare, which were kind of customized to the industry and used technologies that anyone outside of healthcare wouldn’t understand," he added.

But FHIR APIs require health IT developers to publish FHIR endpoints in a standardized format, according to a recent blog post written by Office of the National Coordinator (ONC) officials. By developing the Lantern tool — which consumes public endpoint data, tests the accessibility of these endpoints, and then reports capability information to a public-facing dashboard — ONC worked with health IT stakeholders to form consensus around a standard format to publish FHIR endpoint lists.

How are vendors and providers using it?

A slew of providers, developers, and vendors have created tools that leverage the data standard. The use cases for the standard are nearly limitless and include some of the major challenges preventing healthcare organizations from increasing patient engagement, developing robust population health management programs, and diving into advanced, intelligent clinical decision support.

With enthusiastic support from the ONC and many of the most prominent commercial players in the industry, FHIR is seeing action in several different scenarios.

Cerner Corp. and Geisinger Health System used FHIR to expand population health management capabilities and create specialty-specific applications that break down data siloes.  Epic, Mayo Clinic, and IBM Watson Health leveraged FHIR as the basis for a new clinical decision support model that includes real-time data access for providers at the point of care.

Private industry interoperability efforts like the Healthcare Services Platform Consortium (HSPC) made FHIR the centerpiece of their work to create an EHR-agnostic marketplace for apps that allow data to flow freely across disparate systems. The CommonWell Alliance, Carequality, and the Sequoia Project are also exploring FHIR's potential for creating seamless data exchange.

Nearly in the EHR market has said something about how FHIR will transform the health IT landscape, and they poured plenty of resources into attracting third-party talent to the cause.

Hackathons, developer programs, and connect-a-thons are becoming popular ways to pick out the best and brightest ideas from the health IT community at large.

Epic Systems and Indiana HIMSS announced in 2016 that Eskenazi Health would host a connect-a-thon that will bring local innovators together to use FHIR and APIs to solve longstanding clinical challenges.

The ONC has also launched several FHIR-based app challenges, complete with hundreds of thousands of dollars in prize money. 

FHIR also feature heavily in the ONC's interoperability plans. Part of the information blocking provisions of the 21st Century Cures Act calls on medical providers and health IT developers to encourage patient data access using third-party apps and APIs that support the FHIR Release 4 standard.

"The FHIR standard, in addition to a set of adopted implementation specifications, provides known and consistent technical requirements for software developers," the ONC said.

What does it mean for patients and providers?

Why should patients and providers get excited about FHIR? Because it can make healthcare much more similar to the other internet-based experiences that consumers enjoy in other industries. It may also help make all those wearable devices and monitoring gadgets worthwhile from a clinical perspective.

The healthcare Internet of Things is growing at a lightning pace, but so far, there have been few tools that can connect patient-generated health data (PGHD) with streamlined provider workflows.

FHIR may be the missing link between the EHR and the millions of FitBits, Apple Watches, Bluetooth scales, blood glucose monitors, diet apps, and fitness trackers that are attracting so much consumer attention. This pool of PGHD is growing every day. Still, it is meaningless to providers if they can't quickly and easily access the most meaningful meat of the data, Dr. Nick van Terheyden, Chief Medical Officer at Dell, said to HealthITAnalytics.

"It's not a data problem. It's a filter problem," he said. "Physicians want data, but they want it presented in a way that is useful and actionable for them. I think integrating that information into the existing workflow in a secure manner is really the goal. That's where we will start to see real value."

And that is where FHIR may shine. Situation-specific apps built on an FHIR platform might be able to perform analytics on patient-generated health data and present users with a summary of trends that are relevant to a particular aspect of chronic disease management or patient wellness.

Patients who see multiple providers in different health systems might no longer have to worry about having three or four patient portals from organizations using different EHRs. One single personal health record, which integrates data from different formats to deliver a comprehensive view of all medications, problems, and allergies, could link these disparate systems together to improve care coordination.

Providers may be able to customize their toolsets to meet the needs of their specialty or area of interest, pulling data from different research sources to bolster their clinical decision support capabilities or allowing them to send de-identified information to research registries focused on cultivating a precision medicine approach for the treatment of a rare cancer.

No matter the specific use cases, FHIR revolutionized how developers viewed the underlying technical infrastructure supporting patient care.

The standard is now widely used in mobile applications, cloud communications, EHR-based data sharing, and server communications across the healthcare industry.

"The development and adoption of FHIR was advanced by a remarkable and committed international community," said Charles Jaffe, MD, PhD, HL7 International CEO, in a press release celebrating 10 years of FHIR. "The impact that FHIR has had on global healthcare was driven by an unprecedented level of collaboration that today continues to grow."

Over the past ten years, the FHIR community has achieved success in several key areas, including the Argonaut Project that helped users of a leading platform aggregate and access personal health data on their mobile devices, and the HL7 DaVinci Project, which has helped payers and providers improve clinical quality, cost, and care management outcomes.

The promises of FHIR are many, and the support for the data standard is strong across the care continuum.

HL7 officials expect to launch FHIR Release 5 update this year.

"FHIR is destined to become the underlying ‘network’ that supports health applications everywhere," James Agnew, chief technology officer at Smile CDR and an early FHIR implementer, told HealthITAnalytics.

Though only 24 percent of healthcare companies utilize FHIR APIs at scale, 67 percent of providers and 61 percent of payers expect their respective organizations to use APIs at scale by 2023, according to April 2021 survey data from the Engine Group commissioned by Change Healthcare.

As FHIR continues to underpin data sharing, providers and patients will have access to an incredibly rich set of functionalities within their health IT systems.