Ken Terry

February 28, 2017

ORLANDO, Florida ― A rapidly maturing HL7 standards framework promises to help physicians expand the capabilities of their electronic health records (EHRs) and will make it easier for them to comply with the requirement of the Merit-Based Incentive Payment System (MIPS) that lets patients have easy electronic access to their health information. These budding standards are already starting to have an impact on the healthcare industry.

Showcased in a daylong series of presentations at the recent Healthcare Information and Management Systems Society (HIMSS) 2017 Conference here in Orlando, the data standards, known collectively as Fast Health Interoperability Resources (FHIR), are already allowing physicians in about two dozen healthcare institutions to do things they could never do before with their EHRs. Among the outside applications that FHIR application programming interfaces (APIs) are letting these doctors use are programs for pediatric growth charts, the measurement of bilirubin levels, and the translation of medication instructions in more than 20 languages.

A short list of the institutions using FHIR APIs would include the Geisinger Clinic, the Cleveland Clinic, the Mayo Clinic, Intermountain Healthcare, Duke Medicine, the University of Pittsburgh Medical Center, and Boston Children's Hospital.

Under development for the past 5 years, FHIR uses the same Web standards that underlie most Internet commerce. Snippets of data known as resources represent clinical entities such as medications, problems, and allergies. Data associated with these resources can be plugged into any EHR through an FHIR API without a specialized interface. About 21 of these 100 resources, representing the Common Clinical Data Set developed for meaningful use, have been implemented so far.

The private-sector organization that created these Web-based resources, the Argonaut Project, was formed in November 2014 by leading EHR vendors, healthcare institutions, and consulting firms. Argonaut, which operates under the HL7 umbrella, recently published an implementation guide to help developers create FHIR apps. HL7 itself has published a draft of the FHIR standards, and it expects to approve a "mature" version of those standards this spring, Charles Jaffe, MD, CEO of HL7, told Medscape Medical News.

Some EHR vendors, including Cerner, Epic, Meditech, athenahealth, and Allscripts, are moving rapidly to promote the development of FHIR apps and to make FHIR APIs available to their customers so they can plug in those apps. Some institutions are developing their own apps and are combining them with another technology called SMART (Substitutable Medical Applications and Reusable Technology), which was developed at Boston Children's Hospital. SMART provides a graphical user interface for FHIR apps, along with security and coding tools.

Institutional Resistance

Some institutions are reluctant to turn on their FHIR APIs, Jaffe said. Although there is speculation that these organizations might not want to surrender control over their data, Mickey Tripathi, director of the Argonaut Project, told Medscape Medical News that he doesn't think that is the main reason. Healthcare organizations are already making data available to patients via their EHR portals, he noted. Some provider organizations may have HIPAA privacy concerns, he said, but business associate agreements with app vendors could protect them.

EHR vendors like Cerner and Epic have created digital "sandboxes" for developers so they can maintain some control over the FHIR apps that are available to their customers. But the language of the meaningful use stage 3 and MIPS criteria makes it clear that patients can choose any app they desire to download their data from an EHR. Providers can also select any app they want and access it through the API provided by their EHR vendor, noted Tripathi.

Currently, most of the SMART on FHIR apps are designed for clinicians, Daniel Gottlieb, product and technical lead, SMART Health IT Project, at Boston Children's Hospital, told Medscape Medical News. But he expects many more patient-facing apps to be developed during the next year because of the patient access requirements in meaningful use stage 3 and MIPS.

One problem in using an FHIR app developed in one institution at another healthcare organization is that clinical workflow differences between the two groups or hospitals could impede the app's usage, Grahame Grieve, HL7's FHIR project director, told Medscape Medical News. But Gottlieb noted that some apps, such as Intermountain's bilirubin application, are open source, so they can be customized.

The portability of patient-facing FHIR apps is also limited at present. Although the FHIR standards include an authorization standard that allows an organization to confirm that a patient is who he says he is, the organization may not trust the app that a patient is using to view his records.

"It's not a technical problem, but we haven't set up a trust framework yet," Tripathi noted in the HIMSS presentation. "Until that happens, we won't have the ability for patients to do that."

Write-Back Capability

Currently, Grieve said, most FHIR apps are read-only: that is, they can use the clinical content in an EHR, but they can't become part of the EHR program, which is known as "write-back" capability. "You can't do write-back without [affecting the EHR] workflow, and that's something you need to talk to users about and get buy-in from physicians," he said. Gottlieb added that, by and large, EHR vendors are not supporting write-back yet.

Argonaut's road map for 2017 includes the completion of a provider directory implementation guide and another guide for scheduling apps. The latter is important for patient-facing apps that enable patients to request appointments, Tripathi said. In addition, he said, care managers could use the scheduling features in FHIR apps to improve referral management.

In Tripathi's view, the use of FHIR to improve EHR-to-EHR interoperability is not far off. One sign of that is the decision of CommonWell Health Alliance, a collaborative that includes several big EHR vendors, to build FHIR into its core data exchange services, using the Argonaut implementation guide, he said. CareQuality, another interoperability coalition that recently partnered with CommonWell, is also going down the FHIR pathway, he noted, although in a different way.

Healthcare Information and Management Systems Society (HIMSS) 2017 Conference.

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