2018 is shaping up as a pivotal year for Health Level 7 International’s Fast Healthcare Interoperability Resources application programming interface. Significant momentum continues to build as a growing number of use cases indicate FHIR has reached a tipping point as a mature standard for the electronic exchange of health information.

In March, Apple launched an enhancement to its Health app—which leverages FHIR—enabling patients at 39 participating U.S. healthcare organizations to view their medical records on their iPhones after updating to the iOS 11.3 mobile operating system.

The enhanced Health Records section within the Health app allows patients to see medical data— encrypted and protected with their iPhone passcodes—gathered from various institutions and presented in a single, aggregated view. Patients also receive electronic notifications when their records are updated by providers.

“I’m delighted at the way FHIR has been able to transform patient access to data,” says Chuck Jaffe, MD, HL7’s CEO. “It’s only the beginning of a new era of interoperability and transparency. It goes beyond simply accessing data because in the future there will be solutions for clinical decision support, integration of genomic data, and large-scale population health measures—all of which are supported and this is only the first step.”

Chuck Jaffe, MD
Chuck Jaffe, MD

Adding to the momentum, in March the Department of Veterans Affairs—the nation’s largest integrated health system—launched the VA’s Open API Pledge initiative in which healthcare organizations are voluntarily collaborating with the agency to map health data to industry standards. Specifically, the initiative calls on providers to support current and future versions of FHIR.

So far, 11 major organizations have signed the pledge, including Cleveland Clinic, Geisinger, Intermountain Healthcare, Mayo Clinic, Partners Healthcare and UPMC. They have committed to working with the VA and standards community to implement the existing Argonaut Project implementation guides for the FHIR API.

Also See: UPMC’s Shrestha to help VA with Open API Pledge initiative

The Argonaut Project is a collaboration of health IT vendors and providers seeking to accelerate the adoption of FHIR by creating “road-tested” implementation guides accessible to developers in order to build interoperability capabilities according to modern Internet architectures.

“This is an important lever that can help to move things forward in an industry that is so fragmented,” says Micky Tripathi, manager of the Argonaut Project. “The VA Open API Pledge initiative could be really big. And, in the case of Apple, that’s huge also because it’s a validation from a technology leader outside of healthcare that the standard is mature enough.

“What Apple has done is very positive for the industry because instead of implementing a proprietary standard they have adopted the Argonaut implementation guide,” adds Tripathi, who says that the tech giant has in essence become a testing platform for FHIR. “Apple, then, becomes sort of the benchmark or litmus test for testing conformance with the standard.”

With participants such as Accenture, athenahealth, Beth Israel Deaconess Medical Center, Cerner, Epic, Intermountain Healthcare, Mayo Clinic, MEDITECH, McKesson, and Partners Healthcare, the Argonaut Project has gained significant traction in developing implementation guides for their FHIR implementations. The interoperability framework leverages the latest web standards including a RESTful API, which is designed to use less bandwith than typical access protocols and be more suitable for web use.

“It’s not that the Argonaut Project has really good subject matter experts who can write really good implementation guides,” says Tripathi, who is also president and CEO of the Massachusetts eHealth Collaborative. “It’s that we bring together all of those vendors and provider organizations to scale it across the industry.”

As a member of the Argonaut Project, Cerner sees its EHR system emerging as a technology platform for a plethora of apps that leverage FHIR, enabling physicians to access these pluggable apps directly within their workflow to more easily visualize, interact and transmit health data. “We’re really looking at this as Cerner is a platform versus a product solution,” says Zane Burke, president at Cerner. “We’ll know we’re there when you see a lot of apps on our platform.”

The vendor is encouraging third-party developers to build Substitutable Medical Applications and Reusable Technologies (SMART) on FHIR apps on top of Cerner’s Millennium EHR and HealtheIntent population health platforms. So far, they have 20 validated apps, Burke says.

With the emergence of RESTful APIs leveraged by FHIR, cloud service providers, and machine learning, John Halamka, MD, chief information officer at Boston’s Beth Israel Deaconess Medical Center, believes the industry “suddenly has the perfect storm for innovation.”

Halamka, co-author of Realizing the Promise of Precision Medicine: The Role of Patient Data, Mobile Technology, and Consumer Engagement, contends that innovative third-party apps, modules and services will layer on top of existing electronic health records.

However, he insists that EHRs—in their own right—will not serve as the most valuable tools for personalized care tailored to individuals.

“Epic, Cerner, MEDITECH, athenahealth, eClinicalWorks—they’re all fine, but do I believe that they are going to be the place where we see these innovations? I don’t,” says Halamka. Instead, he contends that “26-year-olds in a garage” will create “novel apps” that “deliver far more usability and utility.”

His vision is of a thriving app ecosystem that produces “Lego building blocks,” which will “sit around the EHR and provide this additional functionality,” creating individually-tailored programs to treat a variety of diseases.

“We’ll leave in place the EHRs we have, but surround them with these kinds of components so that our clinicians and our patients will have a similar experience with cloud-hosted services,” he explains. “It’s a bit like the iPhone and the App Store. The EHR is the iPhone and the iPhone is only valuable today because of the thousands of apps we can buy and add to it.”

In this scenario, Halamka envisions EHRs utilizing FHIR Clinical Decision Support Hooks to send salient patient data to cloud-hosted service providers that curate the medical literature and not only provide a library of evidence but grade the evidence for accuracy, impact, and relevance.

Going forward, Cerner’s Burke says he is optimistic about the potential for real progress in achieving interoperability industry-wide in meaningful ways. “The VA, the Argonaut Project, and work that’s been done with CommonWell (Health Alliance) and others is really coming together around open standards—and, I think these things will continue to evolve,” he concludes.

APIs are included in the 2015 Edition of Health IT Certification Criteria requiring certified EHRs to demonstrate the ability to provide a patient-facing app access to the Common Clinical Data Set via an API.

“ONC didn’t specify that the API has to be FHIR,” notes Tripathi. However, he says based on the latest data “something on the order of 110 to 120 EHR vendors have certified their systems with a consumer-facing API—and, something like 50 percent of those are FHIR-based APIs.”

“The fact is that you just have to have an open API—you don’t have to use FHIR,” comments HL7’s Jaffe. “Why you would want to do that, I don’t know.”

HL7 has published a US Core Implementation Guide—developed in association with the Office of the National Coordinator for Health IT—which defines the minimum conformance requirements for accessing patient data as defined by the Argonaut pilot implementations and the ONC’s 2015 Edition Common Clinical Data Set.

More importantly, last year HL7 published Release 3 of its FHIR Standard for Trial Use (STU), moving closer to a normative version of FHIR.

“My aspiration is to see FHIR Release 4 come out at the end of the year—certainly we’ll ballot it at the end of the year,” says Jaffe. “It’s an opportunity for normative resources for backward compatibility for the kind of insurances that the development community requires for making investments in any technology.”

Release 4 is expected to be the first normative version of FHIR “where the standard becomes stable, and breaking changes are no longer considered,” according to Graham Grieve, FHIR’s product director.

For now, the Argonaut Project is focused on three key use cases using FHIR as well as OAuth security profiles for authentication:

  • Clinical notes, which will enable access to a common set of text-based notes and reports from EHR systems to complement the structured data already covered in the previously published Argonaut Data Query Implementation Guide.
  • Bulk data access of clinical data, which will enable access to structured clinical data (CCDS/USCDI) for a roster of patients to complement the individual patient access already covered in the previously published Argonaut Data Query Implementation Guide.
  • Simple assessment questionnaires, which will enable sharing of an organized set of textual questions and consistent capture and sharing of responses, for example, for an ACO that wants to implement consistent assessments and aggregate responses across disparate EHR systems.

“There are more and more use cases that people want to develop like the 2018 project on clinical notes—that’s very important,” Tripathi says. “Apple really cares about that, as well as providers in general and health exchange networks such as Carequality and CommonWell. Everyone wants to develop clinical notes.”

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