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

March 22, 2017
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.

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.”

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.