Coexistence of FHIR, C-CDA Seen Easing Interoperability Problems

Despite the potential of Health Level Seven’s Fast Healthcare Interoperability Resources (FHIR) to help solve some of the challenges of interoperability, for the foreseeable future government and industry experts predict that FHIR—an application programming interface (API) that leverages the latest web standards—will coexist side-by-side with the Consolidated-Clinical Document Architecture (C-CDA).

“FHIR is particularly useful where you’re looking to query and retrieve specific data elements, not just an entire clinical document,” says Erica Galvez, interoperability and exchange portfolio manager for the Office of the National Coordinator for Health IT, who is leading the agency’s efforts to achieve nationwide interoperability. But, Galvez hastens to add that C-CDA and FHIR serve different purposes.

“It’s really unfortunate to try and line-up C-CDA against FHIR and to do a comparison or a ‘better than,’” she argues. “Frankly, they will probably coexist for some time—maybe forever—if FHIR does continue down a successful trajectory.” However, Galvez cautions that “how rapidly FHIR matures depends on the folks who are creating it.”

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As manager of HL7’s Argonaut Project to accelerate the development and adoption of FHIR, Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, acknowledges that at this point there is speculation on how well and in what cases FHIR will work. “The Argonaut Project has two FHIR APIs, one at the data level and one at the document level. When most people think about FHIR, they think about the data level,” he says. “In healthcare, we actually want documents as well as data to exist in parallel. There are some cases where we want either and there are some cases where we want both.” 

Nonetheless, Tripathi describes C-CDA as having “lots” of limitations. “There are all sorts of issues related to C-CDA,” he says. “It’s a very cumbersome vehicle. It’s not very well standardized, so there’s still a lot of variation even though there is a standard out there. It’s very inefficient because it provides all the data when you ask for only some data.”

At the Massachusetts eHealth Collaborative, for example, Tripathi says that the organization’s data warehouse receives 500,000 to 600,000 C-CDA records per month that are parsed into their atomic data elements and analytics are run on the data, providing Meaningful Use, PQRS, and ACO measures for its customers. “C-CDA can work. It’s just that there’s a lot more work related to getting them to work.”

Still, he admits that “for a while, perhaps a long while” C-CDA and FHIR will coexist, operating in parallel. “We don’t want to throw away what is starting to work,” asserts Tripathi. “The market has made a lot of progress I think, and the current C-CDA standardization and work on the next version of C-CDA is actually going to be much more constrained than the previous versions and we’re starting to see people use them. I would hate to abandon all that.”

Tripathi has committed his organization to serve as the manager for the Argonaut Project which is seeking to rapidly develop a first-generation FHIR-based API and core data services specification to enable expanded information sharing for electronic health records and other health IT. According to Tripathi, 40 organizations have joined the Argonaut Project in this effort including athenahealth, Beth Israel Deaconess Medical Center, Cerner, Epic, Intermountain Healthcare, Mayo Clinic, Meditech, and McKesson.

“We are paying attention to the work that is going on in the private sector,” says Jodi Daniel, director of ONC’s Office of Policy, referring to the Argonaut Project. “If there is a standard that is mature and that has industry support, we will strongly consider that in our activities.”

However, in comments to ONC on its draft nationwide Interoperability Roadmap, the HIMSS Electronic Health Record Association strongly urges the agency to “make a realistic assessment of the readiness and maturity of the emerging and very promising HL7 FHIR standard.” According to EHRA, the Interoperability Roadmap “needs to account for several critical facts, not the least of which is that the FHIR standard is not yet final or complete.”

As a result, over the next three years, the organization recommended ONC assess the “collective progress” and to “specify and pilot a successful first level of FHIR deployment that can be bridged with C-CDA document push (Direct) and pull (XDS/XCA).”