Interoperability: The FHIR standard is not a panacea

The FHIR (Fast Healthcare Interoperability Resources) standard for exchanging healthcare information was created by the Health Level Seven (HL7) International standards organization and originally published in draft form in 2014. Although most physicians need not be concerned with the details of the FHIR standard, high expectations exist that the standard will improve interoperability. And interoperability, as demonstrated in a recent study by Deloitte, is a primary concern of most primary care physicians. Let’s examine FHIR’s impact on interoperability more closely.

It is generally agreed that FHIR represents an improved technical standard as it is based on current web standards like JSON and API (Application Programming Interface) technology. In addition, FHIR integrates transport and security mechanisms into the standard, which is an exciting advancement. 

True interoperability requires that two conditions be met. The first (as mentioned above) is technical interoperability, or the ability to transmit data from one place to another. Think of laying an undersea telegraph cable from North America to Europe as a metaphor for technical interoperability. The second component is semantic interoperability, which is the ability to transmit data from one place to another with meaning. In our undersea cable example, if the sender writes French but the receiver understands only English, semantic interoperability has not been achieved even though technical interoperability exists.

The FHIR standard will be challenged in the realm of semantic interoperability because of the use of different coding systems which will require data normalization regardless of the transport technology employed. As a simple example, Source A may provide an ICD-10 code for Heart Failure while Receiver A is expecting a SNOMED code. Mapping the ICD-10 code system to SNOMED would be required for semantic interoperability. While this is a simple example, clinical data created by hundreds of certified Electronic Health Records (EHR) documented by millions of clinicians are highly de-normalized and require technology middleware for effective, scalable data normalization.

Standards aside, there are three macro level issues which will delay the complete adoption of FHIR, likely for years: lack of mandate, lack of consensus for a common FHIR standard, and business restrictions from EHR developers. A few comments about each:

• No FHIR mandate-Unlike Meaningful Use and its requirements for the CCD (Continuity of Care) document, there is no current government mandate for a specific version of FHIR standard resources. Whatever your view of the Meaningful Use program, it was an effective forcing mechanism in digitizing EHR data and requiring that every certified EHR be capable of producing care summaries. Consequently, there are hundreds of millions of CCDs exchanged annually.
• Currently many EHRs and health information vendors have adopted version 2 of FHIR while others are working on the current FHIR release (version 3) while others are awaiting the next balloted release (version 4). The fast, iterative development of FHIR has been a catalyst for much optimism about the long-term power of the standard, but without a single stable release for developers to consolidate around, near-term adoption may be mixed.
• Restrictions from EHR developers-currently EHR developers are fabricating “read only” FHIR resources and not supporting the capability to write back to the EHR. Physicians using EHRs are understandably skeptical about importing outside clinical data into the EHR without validation. This substantially reduces the power of an application ecosystem of medical apps powered by FHIR, when no app can create an order or trigger a workflow within the EHR. Consequently, the pace of FHIR adoption will be slowed due to more limited use cases. 

With that said, what can organizations do to be ready when the FHIR alarm sounds?

• Send technical staff to FHIR training events, like the FHIR Connectathon and Dev Days, which can increase FHIR skills as well as staff motivation
• Think globally, and act locally-start with small projects with measurable benefits that build upon success while increasing the team’s capabilities
• Remember that, regardless of the standard used, semantic interoperability will present the biggest challenges to effective interoperability

As many in the HL7 and standards community regularly reaffirm, interoperability of medical data will be a long journey with no end in sight. FHIR is a great step forward along that path, but is not a panacea for the industry’s woes and must be complemented by larger investments in data quality, application development and trust in data exchange. 

John D’Amore is president and chief strategy officer for Diameter Health.