Tuesday, October 23, 2018

Should I jump into the FHIR right now?

I get this question a lot, especially when I teach FHIR, which is a new HL7 standard for electronic
exchange of healthcare information, as there seems to be a lot of excitement if not “hype” about this topic.

My answer is usually “it depends” as there is a lot of potential, but there are also signs on the wall to maybe wait a little bit, until someone else figures out the bugs and issues. Here are some of the considerations that could assist your decision to either implement FHIR right now, require it for new healthcare imaging and IT purchases, or start using it as it becomes available in new products.

1.      The latest FHIR standard is still in draft stage for 90% of it – That means that new releases will be defined that are not backwards compatible. That means that upgrades are inevitable, which may cause interoperability issues as not all new products use the same release. As a matter of fact, I experienced this first hand during some hackathons as one device was on version 3 and the other one on version 2, which caused incompatibilities. The good news is that some of the so-called “resources” such as those used for patient demographics are now normative in the latest release so we are getting there slowly.

2.      FHIR needs momentum – Implementing a simple FHIR application such as used for appointments requires several resources, for example patient demographics, provider information, encounter data, and organization information. If you implement only the patient resource but use “static data” for example, the remainder is subject to updates, changes, and modifications, etc., in other words, if you slice out only a small part of the FHIR standard, you don’t gain anything. Unless you have a plan to move the majority of those resources eventually to FHIR, and upgrade as they become available, don’t do it. The US Veterans Administration showed at the latest HIMSS meeting how they exchange information between the VA and DOD using 11 FHIR resources that allowed them to exchange the most critical information. When implementing more than 10 FHIR resources you achieve critical mass.

3.      Focus on mobile applications – FHIR uses RESTful web services, which is how the internet works, i.e. how Amazon, Facebook and others exchange information. You get all of the internet security and authorization for free, for example, accessing your lab results from an EMR could be simple by using your Facebook login. The information is exchanged using standard encryption similar to what is used to exchange your credit card information when you purchase something at Amazon. Creating a crude mobile app can be done in a matter of days if not hours as is shown at the various hackathons. Therefore, use FHIR where it is the most powerful.

4.      Do NOT use it to replace HL7 v2 messaging – FHIR is like a multipurpose tool, it can be used for messaging, services, and documents, in addition to having a RESTful API, but that does not mean it is a better “tool.” One of the traps that several people fell into when HL7 version 3 was released, which is XML based, is that they started to implement new systems based on this verbose new standard, because it “is the latest,” without understanding how it would effectively choke the existing infrastructure in the hospitals. Version 2 is how the healthcare IT world runs, it is how we get “there” today and how it will be run for many more years to come. Transitioning away from V2 will be a very slow and gradual process, picking the lowest hanging fruit first.

5.      Do NOT use FHIR to replace documents (yet) – EMR to EMR information exchange uses the clinical document standard CDA, there are 20+ document templates defined such as for an ER discharge, which are critical to meet the US requirements for information exchange, they are more or less ingrained. However, there are some applications inside the hospital where a FHIR document exchange can be beneficial, for example, consider radiology reports, which need to be accessed by an EMR, a PACS viewing station, possibly a physician portal, and maybe some other applications. Instead of having copies stored in your voice recognition system, PACS, EMR, or even a router/broker or RIS, and having to deal with approvals, preliminary reports, and addendums at several locations, it is more effective to have a single accessible FHIR resource for those. One more comment about CDA; there is a mechanism to encapsulate a CDA inside a FHIR message, however, for that application you might be better off using true FHIR document encoding.

6.      Profiling is essential – Remember that FHIR is designed (on purpose) to address 80% of all use cases. As an example, consider the patient name definition, which has only the last and first (given) name. Just to put this in perspective, the version 2 name has xx components (last, first, middle, prefix, suffix, date of xxxxx etc.). What if you need to add an alias, a middle name, or whatever makes sense in your application? You use a well-defined extension mechanism, but what if everyone uses a different extension? There needs to be some common parameters that can be applied in a certain hospital, enterprise, state or country. Profiles define what is required, what is optional, and any extensions necessary to interoperate. I see several FHIR implementations in countries that did not make the effort to do this, for example, how to deal with Arabic names in addition to English names is a common issue in the Middle East, which could be defined in a profile.

7.      Develop a FHIR architecture/blueprint – Start with mapping out the transactions as they are passing through the various applications. For example, a typical MPI system today might exchange 20-30 ADT’s, meaning that it communicates patient demographics, updates, merges, and changes to that many applications. Imagine a single patient resource that makes all of those transactions obsolete as the patient info can be invoked by a simple http call whenever it is needed. Note that some of the resources don’t have to be created locally, a good example is the south Texas HIE, which provides a FHIR provider resource so you never have to worry about finding the right provider, location, name, and whether he or she is licensed.

8.      Monitor federal requirements (ONC in the US) – Whether you like it or not, vendors may be required to implement FHIR to comply with new regulations and/or incentives, including certification. In order to promote interoperability, which is still challenging (an understatement), especially in the US where we still have difficulty exchanging information even after billions of dollars spent on incentives, ONC is anxious to require FHIR based connectivity. This is actually a little bit scary given the current state of the standard, but sometimes, federal pressure could be helpful.

To repeat my early statement about FHIR implementation, yes “it depends.” Proceed with caution, implement it first where the benefits are the biggest (mobile), don’t go overboard and be aware that this is still bleeding edge and will take a few years to stabilize. If you would like to become more familiar with FHIR, there are several training classes and materials available, OTech is one of the training providers, and there is even a professional FHIR certification.