Charles Jaffe, M.D., Ph.D., has led HL7 as its CEO since 2007. The organization is on the leading edge of standards development, and is working on refining its Fast Healthcare Interoperability Resource (FHIR) standard. The platform uses coding and URL calls to facilitate the exchange of healthcare information. It’s attracting a lot of attention, and organizations are using the current version of FHIR to enable healthcare information exchange that was previously difficult to achieve.
As HL7 continues to develop and evolve the standard, Jaffe took time to answer some questions about the current status of the FHIR standard, the development work that is ongoing, and the role FHIR can play in improving information exchange within healthcare.
Tell us about the process for developing FHIR standards. They are still in the development stage, but also beginning to be implemented and used in real-life settings, right?
As the stakeholder community recognizes, FHIR is still under development. At the same time, both the standard developers and the implementers anticipate that the specification will continue to evolve. The feedback that we receive during this process help to inform future releases. Much of this work is driven by the Argonaut Project, the private sector initiative that emerged from the ONC Jason Report. In fact, the efforts of the Argonaut community drives both FHIR specification development as well as a broad spectrum of implementation initiatives.
Cerner, as one example, is a company that’s incorporated FHIR into one of its apps. How is that indicative of FHIR’s progress?
Cerner has built FHIR solutions based the first stable release of FHIR, which we referred to as 1.1. Many other organizations, including those in the EHR vendor community, academic centers and government agencies, have followed suit. With the new release of these specifications, we have achieved much more stability than those based upon previous iterations of FHIR. They are ready for system to system use, because the current FHIR release has implemented the ISO standards called Open ID and OAuth. With this version, organizations can authenticate users and ensure security with ISO-standard technology.
Is it a concern that FHIR is evolving? Will a change in standards mean applications using the current release will need work as FHIR is refined?
There are a couple principles that I strongly embrace. Any standard that doesn’t change, even when it is a stable standard, hasn’t kept up with the world we live in. For example, when I was an intern, the ICD codes we used for asthma and bronchitis were the same. Now, our understanding of those problems has evolved. We would not like ICD or any other standards to be immutable. That approach is tantamount to denying progress in biology and in healthcare delivery. With the tremendous progress and the dramatic change in the care delivery paradigm, not only has the technology changed but our business process has changed. It will continue to evolve, and standards need to keep up with them. I don’t have any notion of what the future may bring, but I know the standards will change.
How is HL7 pursuing this evolution in the FHIR standard?
It’s a continual process. It’s being achieved in three ways. First, there are continuous feedback loops. Many of the HL7 work groups have weekly meetings to discuss and refine specific aspects of FHIR. The second way is through testing FHIR on different testing modalities and platforms. And the third path is through a ballot. Stakeholder groups are charged with voting on the characteristics of a standard.
How widespread is the adoption of FHIR?
Most of the industry’s EHR vendors – including Epic, AthenaHealth, McKesson and others – have vibrant FHIR programs in place. Secondly, there are federal agencies that are very supportive. The federal health architecture, FDA, CDC and other federal agencies are participating. There are communities of interest out there that develop and teach this in academia. The payer community had our first and largest FHIR following. They see the importance of using FHIR to access’ patients clinical information, which has greater validity that claims submissions. Finally, the BioPharma industry has seen great value in leveraging the FHIR platform for multiple strategic uses, including gathering clinical data for regulatory submissions.
Why are the hopes so high for FHIR?
In many cases, FHIR is emerging as the initial choice for application development, particularly in a green-field environment. In everyday development, FHIR is both easy to learn and agile in the development process. It requires a knowledge of programming now typically taught in high school. FHIR holds great promise that is yet to be realized. There are so many opportunities to use it; not only in unique applications within an EHR, but also between EHRs and across delivery systems. As we move into evolving realms, such as enhanced clinical decision support, as well as the areas of genomics and precision medicine, the ease and speed of FHIR implementation will become even more valuable. This approach translates into greater innovation, more open access to data and lower costs. We envision this in almost every realm of our health system, from clinical research to care delivery to patient engagement.
What are some of the challenges that you see ahead for interoperability?
There are hurdles that go beyond the transport standards. For example, there is inherent complexity within clinical medicine, even areas that seemed simplistic to a prior generation of providers. At another level, we cannot overlook the complexity of biological systems. An ATM machine has 10 data elements. The English language has 400,000 words. The National Library of Medicine has identified 2.4 million unique terms. We cannot overlook the complexity of terminologies that are inherent in healthcare. Communicating that to our stakeholder is a much greater challenge than agreeing on the next iteration for FHIR.
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