What Lessons Did Public Health FHIR Pilots Learn?

A new report describes the learning curve involved in efforts to accelerate FHIR maturity within the public health community. Pilot project participants said that initial projects require time to build familiarity with the FHIR standard and implementation processes, such as data mapping, translation, use of specific file formats, and initial setup of FHIR servers and infrastructure.

The Association of State and Territorial Health Officials (ASTHO) report, co-authored by Ankur Jain, Ashley Ottewell, and Elizabeth Ruebush, notes that adopting FHIR for data exchange can equip public health agencies with a modern, interoperable framework to efficiently share information with providers, laboratories, and government agencies.

The pilot sites were comprised of state/local health departments and data exchange partners. Each pilot involved a data exchange pair, including:
• Minnesota Department of Health and Hennepin County Public Health
• Virginia Department of Health and Fairfax County Health Department
• Washington State Department of Health and Public Health — Seattle & King County
• Philadelphia Department of Public Health and the HealthShare Exchange HIE

Several other organizations provided technical support. As the report describes, in 2022 the Public Health FHIR Implementation Collaborative (PHFIC) kick-started a community that focused on improving public health data exchange through use of the FHIR standard. Convened by the CDC, PHFIC brings stakeholders together to test FHIR-based solutions in real-world settings. It has advised three phases of public health FHIR pilot projects.

Through these pilots, PHFIC identified lessons learned, and developed resources to support other health agencies in adopting FHIR, such as the Public Health FHIR Playbook, released in 2023.

In the pilot involving the Washington State Department of Health (DOH) and Public Health Seattle & King County (PHSKC), the organizations were seeking to reduce data silos across programs within the DOH, between the state and local health jurisdictions, and between public health and health care systems. DOH and PHSKC began with one-way data sharing of death record data, followed by advancing to bi-directional exchange, and finally integrating immunization data into the exchange.

Aiming to reduce the burden associated with manually accessing individual immunization records, DOH and PHSKC are working to support bulk FHIR transmission of immunization data from the state immunization registry to the county. This effort aligns with activities of the HL7 Helios Project Bulk Data Priority Area.

Here are just a few of the challenges identified by the pilots: 

• Several pilot sites reported having limited or varying levels of FHIR knowledge and experience at the outset of their projects. Time and training are crucial to building a “FHIR-savvy” public health workforce, and to upskill the project team.

• Pilot sites also noted that many health departments are not yet working on FHIR implementation and/or may be prioritizing other data modernization efforts. This dynamic may limit the availability of willing exchange partners, peer learning opportunities, and colleagues working on refining implementation guides and other implementation tools.

• Available funding did not always cover total FHIR-associated implementation costs since annual funding cycles are not well aligned with the time and resources needed to plan and implement FHIR projects, or to produce contract deliverables.

Pilot participants recommended developing an agency-level FHIR roadmap to help guide infrastructure development over time and support teams in prioritizing use cases. At the project level, an implementation plan with key milestones, deliverables, and timelines is important for guiding work and aligning team expectations.

They emphasized thinking longer-term and building a reusable FHIR-based infrastructure. When implementing new technologies or approaches for a specific use case, it is important to consider their applicability to broader agency and public health functions, the report said. Establishing reusable FHIR-based infrastructure requires early and sustained planning, beginning with the initial implementation. Emphasis should be placed on scalable, standards-based solutions that can be adapted across multiple use cases to support long-term interoperability and efficiency.

The ASTHO report says that the momentum from these pilots offers a path forward, and that ongoing pilot projects should explore and refine new use cases and that implementation guides can provide replicable models and technical documentation that other jurisdictions can adopt and adapt.

Pilots can serve as peer mentors and incubators for new use cases, further advancing the development and adoption of FHIR-based data standards. 

Health departments can also integrate FHIR implementation efforts into other initiatives, such as the Public Health Data Modernization Implementation Center Program, to ensure continued momentum.

The report says that future initiatives should support strategic planning for sustainable FHIR infrastructure that aligns with national priorities such as the Public Health Data Strategy, and frameworks such as the Trusted Exchange Framework and Common Agreement (TEFCA).