What is FHIR? The eventual answer to healthcare interoperability

Fifteen years after President George W. Bush launched a nationwide campaign to computerize healthcare and give everyone access to their electronic health records (EHRs), the industry is finally starting to achieve some degree of interoperability among EHRs and other health IT systems. But much of the data is still locked up in documents, and the ability of healthcare providers to access discrete data from outside sources at the point of care remains limited.

The reason interoperability between computer systems is so difficult in health care—and the reason it’s so badly needed—is that health care is extremely fragmented. There are many different kinds of healthcare providers, including hospitals, doctors, nursing homes and urgent care centers, and they use many different types of EHRs. Health insurers use an array of other systems. Interfaces are expensive to build and difficult to maintain, and they don’t allow searches across networks.

Complicating this already complex scenario is the fact that, for their own business reasons, some EHR vendors and provider organizations have created barriers to electronic health data exchange. A recently proposed rule from the federal Office of the National Coordinator of Health IT (ONC) would prohibit such “information blocking” and would also make it easier to exchange discrete data by requiring that government-certified EHRs include APIs based on the emerging FHIR standard.

What is FHIR?

Fast Healthcare Interoperability Resources (FHIR) is a healthcare-specific standards framework for the same kind of RESTful APIs that underlie most internet commerce. Snippets of data known as resources represent clinical entities such as medications and medical problems. FHIR-based apps can be plugged into any FHIR-capable EHR without a customized interface.

In theory, it sounds like problem solved. But experts and CIOs tell cio.com there is still a long road ahead before FHIR is widely adopted for EHR-to-EHR interoperability. Today, the major use cases for FHIR-based apps are to expand EHR functionality and to enable patients to download their records and make use of them in various ways. For example, the Apple Health Records app now uses FHIR to enable consumers to download health information from multiple providers and assemble them into a single health record on their iPhones.

Meanwhile, healthcare providers have several other ways to exchange patient data electronically. In many cases, their interoperability options depend on the kind of organization they’re part of, where they’re located, and what kind of EHR they have. But the experts note that the progress made to date is fairly impressive, considering that most health records were still on paper 10 years ago.

Referring to a recent survey showing that 29% of hospitals have systems capable of semantic interoperability, Douglas Fridsma, MD, president and CEO of the American Medical Informatics Association (AMIA), said, “That’s huge. It took 25 years for the financial industry to get ATMs to talk to one another. And the semantics of a bank transaction are relatively simple. In the much more complicated space of healthcare, we’ve made a lot of progress.”

How health data is exchanged today

The backbone of health information exchange today is still the plebeian fax. For many medical practices, hospitals and nursing homes, faxing remains the go-to method of referring patients, receiving discharge summaries, and exchanging clinical documents. They’re now computer-faxing each other, but that’s not very much progress.

The next step beyond faxing is Direct secure messaging, a specialized form of email created several years ago by a public-private consortium. Direct messages are conveyed by “health ISPs” between providers who have Direct addresses, including most physicians. All certified EHRs are capable of exchanging Direct messages. Attached to these messages may be standardized clinical summaries known as Consolidated Clinical Document Architecture (CCDA).

DirectTrust, which created the trust framework needed to authenticate Direct messages, reports that over 164 million of them were sent and received in the first quarter of 2019, up 49% from a year earlier. David Kibbe, MD, the former president and CEO of DirectTrust, believes that the upsurge in Direct messaging is due to growing uptake by hospitals.

Statewide and regional health information exchanges (HIEs) also grease the wheels of interoperability—where they exist. Five years ago, there were 106 operational HIEs in the US. Today, there are probably about the same number, says Julia Adler-Milstein, part of the research team that has been surveying HIEs periodically for the past decade. An associate professor at the University of California San Francisco, Adler-Milstein estimates that about half of the current HIEs claim to be statewide, but only about a quarter really are.

HIEs principally move patient summaries, test results, and admission-discharge-transfer (ADT) alerts from hospitals to other providers. Because of the rise of Direct messaging and other data exchange methods, this activity has become “commoditized,” Adler-Milstein says, so HIEs are trying to provide value-added services such as social services and emergency preparedness.

Network services propelled by EHR vendors largely provide the same services that HIEs do, but in a more efficient way and with a national scope. CareQuality, the first such nationwide service, encompasses EHR companies, HIEs, record location services, and other networks. CareQuality is built into some major EHRs, including Epic, the biggest supplier of hospitals and physicians in the private sector.

Epic’s Care Everywhere enables customers to exchange information among themselves. In addition, they can use CareQuality to exchange messages with all CareQuality participants. That includes customers of other EHR vendors and many regional and state HIEs, which use CareQuality in place of expensive interfaces with disparate EHRs. 

A second network service, CommonWell Health Alliance, was formed by other EHR vendors but doesn’t include Epic. CommonWell, which focuses more on record location than CareQuality does, now participates with CareQuality as a network. The EHR vendors in the two network services represent more than 90% of the acute-care hospital market and nearly 60% of the ambulatory-care (non-hospital) market.

Do HIEs have a future?

CareQuality and CommonWell will eventually replace statewide and regional HIEs entirely, predicts John Halamka, MD, executive director of the Health Technology Exploration Center of Beth Israel Lahey Health and former CIO of Beth Israel Deaconess Medical Center in Boston. Micky Tripathi, director of the Argonaut Project, which has done the bulk of FHIR development work, agrees. Unless the government takes interoperability in a different direction, he says, “CareQuality and CommonWell will be the de facto national network.” HIEs that provide value-added services may survive, he adds, but many others will be disintermediated.

Some regional HIEs are thriving. For example, the Geisinger Health System, a large integrated delivery system based in Danville, Pa., helped build and still depends on the Keystone Health Information Exchange (KeyHIE). John Kravitz, CIO of Geisinger, says KeyHIE connects 175 entities, including health systems, post-acute and long-term-care providers, physician groups, health plans and others. KeyHIE exchanges 3.25 million documents and delivers 26,000 notifications per month, he notes.

Indranil Ganguly, vice president of information technology at Hackensack Meridian Health, says that some of the health system’s eight hospitals still use Jersey Health Connect, a regional HIE, for sending out lab results and ADT alerts and as a patient portal. But Hackensack Meridian is in the process of converting all of its hospitals to an Epic EHR. After that transition is completed in the fall, he expects the health system will drop the HIE and start using CareQuality to connect with outside providers. At the same time, it will switch to Epic’s MyChart patient portal.

Exchanging documents vs. discrete healthcare data

The interoperability methods described so far are mostly used to exchange documents of various kinds. The information in those documents can help clinicians diagnose and treat patients. But busy physicians often find it difficult to locate the data they’re seeking in CCDAs, which are long, complex documents. And when they do find it, they may have to copy the information into their EHRs.

Things have improved over the past few years, Kravitz notes. First, the CCDA document goes right into the patient record, rather than into a separate area of the EHR. Also, clinicians no longer have to cut and paste every piece of data they need into their electronic charts. Epic can consume a patient’s medications, problems and allergies from the CCDA and send it into the correct EHR fields after asking the clinician’s permission, he points out.

Nevertheless, that’s still only a small part of what’s in the clinical summary. In addition, physicians might want only to locate and pull in a portion of the patient’s record from a different EHR, such as their current medications. That’s why the FHIR approach is so appealing to CIOs and interoperability experts.

Halamka is placing his chips on FHIR. The newly merged Beth Israel Lahey Health is currently using an FHIR-like API approach he developed years ago that permits read-only access to the system’s EHRs, which include multiple instances of Epic, Meditech, athenahealth and Cerner. “We’ll switch it to the FHIR apps once they are fully substantiated in FHIR EHRs,” he says.

The Argonaut Project and FHIR obstacles

Over the past few years, the members of the Argonaut Project, which include leading technology vendors and healthcare organizations, have developed implementation profiles for more than two dozen FHIR resources. Most of these resources represent the same categories that are in the CCDA. The Argonauts have expanded their guide to include scheduling, provider directories and radiology ordering, Tripathi says, and are now updating their original resources to accommodate the latest version of FHIR from standards organization HL7.

Tripathi estimates that the profiled resources cover about 80% of the information that doctors commonly need and are interested in exchanging. But that’s a small percentage of the data in an EHR, including the unstructured text that forms the majority of its content. Also, a big chunk of the structured data has not been coded to allow semantic interoperability, because the codes don’t match all of the terms used for the same concept.

This creates problems for using FHIR APIs to create interoperability between disparate EHRs, notes Halamka. “The challenge there is referential integrity. When you enter an allergy [in the EHR], inside the business logic of the EHR it might say, ‘This allergy is due to an adverse reaction, and here’s a table of adverse reactions.’ It’s all designed to have integrity in that EHR’s database. Now what if you’re getting data from the outside, and what if Epic calls the reaction hives, and Cerner calls it urticaria? When you try to incorporate Epic data into Cerner data, there’s no term for that in the referential integrity table.”

Therefore, Halamka says, new FHIR resources must be created and profiled to cover more of the content of EHRs before they’ll be plug-and-play with each other. Kravitz agrees. “More FHIR integration has to be developed so you can have deeper access to information,” he says. In addition, because vendors worry that outside apps might corrupt their databases, FHIR-based apps currently have read-only access to EHRs, he notes. No writeback is allowed.

“Right now, FHIR integration is mostly outbound,” Kravitz says. “There’s just one area that’s inbound, and those are just text-based documents. Discrete data inbound via FHIR is not occurring right now.”

Another obstacle to FHIR-based interoperability, Tripathi says, is that healthcare organizations won’t drop their current methods of information exchange overnight. For example, CareQuality and CommonWell use a SOAP-based exchange protocol called Integrating the Healthcare Enterprise (IHE) as the core of their services. However, CareQuality has converted its provider directory to FHIR resources and is figuring out how to adapt IHE to FHIR by specifying the necessary non-FHIR elements, says CareQuality executive director Dave Cassel.

The future of interoperability

Meanwhile, FHIR will be used mainly for exposing EHR data to apps that allow clinicians to increase their EHR functionality and make it easy for patients to download their records. In the latter connection, there will inevitably be security and privacy concerns. So far, Tripathi says, healthcare organizations are authenticating patients on their patient portals, and EHR vendors are registering apps developed by third-party vendors and the healthcare systems themselves.

Halamka thinks there should also be regulations governing how patients’ privacy is safeguarded after they move their health data to third party apps. “The [U.S.] Office of Civil Rights says that if a patient requests their data and it’s given to them in a secure manner, and then that data is spread all over the world, that’s not the responsibility of the HIPAA-covered entity. But as a CIO and as a patient, you need to have some kind of certification of these apps. The rules suggest we can’t say ‘No,’ but I hope we develop something additional over time to authorize certain apps as good enough.”

Doug Fridsma, who used to be director of the Office of Standards and Interoperability for ONC, is very optimistic about the future of interoperability. Although the government has gotten a lot of pushback from the industry for its aggressive timeline in the ONC rule, he says that requiring FHIR-based APIs in EHRs will be a big step forward. Meanwhile, he notes, interoperability is improving on a number of other fronts.

“Interoperability is not some place, some verdant pasture flowing with milk and honey,” he says. “People always ask, ‘Why aren’t we there yet? Why isn’t there some ubiquitous data flow going everywhere?’ That’s not how it works. Interoperability is not a place that you arrive at. It’s a milestone on the way to better patient care.”