When the final interoperability rules issued in March by the Office of the National Coordinator for Health IT (ONC) and the Centers for Medicare & Medicaid Services (CMS) called for using FHIR and standard application programming interfaces (APIs), it was seen as a game changer.
“We have been waiting for this, but it kind of formalizes the importance and criticality of FHIR in the world of healthcare information,” says Wayne Kubick, chief technology officer for the nonprofit HL7 standards organization. “It is one thing to say it is going to happen someday. It is quite a different thing that it actually did happen. We are in a world dealing with a health crisis and it just reinforces the importance of information being readily available, exchangeable and usable, no matter where it comes from, to be used at the macro level, from the public health level, and from the individual level in terms of treating patients.” Providers have to be flexible, he adds, and FHIR makes it possible to build solutions rapidly. “That just wasn’t the case with the technologies from a few years ago.”
The ONC final rule calls for use of FHIR Release 4, which is the release with the first normative content. Developers can build around it and not worry about backward compatibility with the core technological components, Kubick says. Release 5 is expected sometime in 2021.
One of the visions clinical informatics executives have had is that a thriving FHIR-based app market would develop atop EHR platforms, so that innovations could be spun up more rapidly. While those EHR app stores have developed, there is still more work to do to totally unleash them. “When we did application roundtables, we were surprised to see how many small startups were using FHIR to build things the world just wasn’t aware of,” Kubick recalls. “Their time is coming now. We will see a whole lot more popping up.”
One of the things that has allowed rapid progress has been the creation of a series of HL7 “FHIR Accelerators” to focus on use cases that are of critical importance to stakeholders, including the initial accelerator focused on clinical settings, the Argonaut Project.
A Da Vinci masterpiece
One of the FHIR accelerators that has made considerable progress over the past year is the Da Vinci Project, which was launched in 2018 as a multi-stakeholder effort led by payers, providers and health IT vendors to address use cases in value-based care. The group wanted to cut down on custom one-off work between payers and providers and reduce the need for unique solutions.
Jocelyn Keegan, payer practice lead for consulting firm Point of Care Partners and program manager of the Da Vinci Project, says that after defining numerous use cases and working through the HL7 balloting processes, now is the time for the project members to start using the interoperability guides. “We are at an inflection point where the roles and responsibilities pivot from the project team back to the membership as the implementation guides are being used in a pre-production and production environment.”
The group is working on projects around data exchange for quality measures and coverage requirements discovery. Some members are going live with coverage requirement discovery pilots that would allow a physician to see any prior authorizations or requirements before scheduling a patient for surgery, for instance. “This can help steer that patient’s journey and improve outcomes,” Keegan says, “by bringing benefit information right alongside the care and treatment plan.”
The key to progress is to identify solutions that have real return on investment for both providers and payers, she says. “Our approach is by looking at things on a use-case basis, and now grouping those into families and areas, we can create a community of people who work on these problems every day. We give them a place to share those solutions and add examples. It is very rare in a career to be in a place where an industry is fundamentally changing how it works, and at Da Vinci, we are getting to experience that.”
Feeling gravity’s pull
Building on work done by researchers at the Social Interventions Research & Evaluation Network (SIREN) at the University of California San Francisco, the project was not initially FHIR-focused. “We were focused on identify data definitions for documenting social determinants of health in clinical systems, which involves defining what we mean by food insecurity, housing instability, and transportation needs,” explains Evelyn Gallego, the Gravity Project’s program manager and CEO of EMI Advisors LLC. “We were geared toward coded data definitions and applicable codes and value sets for grouping them.”
But Lisa Nelson, who was working on the Da Vinci Project at the time, suggested that the Gravity Project also consider a FHIR framework. Nelson, who is now technical director of the Gravity Project, is vice president of business development and marketing and principal informaticist at MaxMD. “I remember saying to Evelyn that if you want to affect use cases that are oriented toward sharing this information–with researchers and organizations doing care coordination—it is insufficient to just generate a set of codes,” Nelson says. “You have to have sharing mechanisms that are standards-based. We tried to think how Gravity could reuse data-sharing methods being developed rapidly in other areas using FHIR but bring our content to those mechanisms.” Gallego says defining meaningful use cases has created a strong community that has grown to 900 people working on Gravity. “We developed personas, envisioning the type of people who would be helped by this kind of data sharing, a patient story that represented the data-sharing needs that must be addressed.”
Starting with food insecurity, they recognized three use cases: The first is collecting social determinant of health information in the context of clinical care; the second is a closed-loop orchestration of tracking referrals; the third is sharing data gathered in the clinical setting with other secondary users to enable quality measurement, risk stratification and population health management.
“The food insecurity work is the first round of content that pours onto some very generalized approaches that we will be using,” Nelson says, “so that when we get done with this first round, housing and transportation will just run right on these same rails.”
FHIR bulk data
Another significant FHIR development this year involves a FHIR bulk data specification. When ONC issued its interoperability final rule in March, it made clear that in the future certified EHR vendors would need to show they can do bulk data export.
As Josh Mandel, M.D., chief architect at Microsoft Healthcare and a lecturer on biomedical informatics at Harvard Medical School, explains, FHIR bulk data and back-end services specifications allow one party that is managing a whole population’s worth of records to be able to provide those in a standardized, exportable format to share the whole set or subsets with another party. “ONC was interested in supporting value-based care models in which a payer might have one set of data about a population and a provider might have another set,” he says. Together those two sets of data could be used to reach a deeper understanding of who might be eligible for disease management programs, for example.
“The FHIR bulk data spec basically says we have a set of data models now in FHIR, including this U.S. Core Data for Interoperability (USCDI), that every EHR needs to be able to support,” Mandel says. “Rather than negotiating every time about how we are going to do export, what if we just do it in a standard way? This gives everybody something they should be able to use out of the box.”