FHIR: shaping the future of health data exchange


HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More FHIR® began with an open ended question: What would health data exchange look like if we started from scratch using modern approaches? To answer this question, HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More turned to other industries for ideas. Recent interoperabilityInteroperability refers to the ability of two or more systems or components to exchange information ... More successes pointed strongly to the use of RESTful based APIs.

HL7 FHIRFHIR stands for Fast Healthcare Interoperable Resource. This emerging standard combines the best fea... More combines the best features of HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More V2, HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More V3, and CDAClinical Document Architecture (CDA) HL7 CDA uses XML for encoding of the documents and breaks down ... More, while leveraging the latest web service technologies. FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More is based on modular components called “resources.” and these resources can be combined to solve clinical and administrative problems in a practical way. FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More is still being developed by HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More, but the third Standard for Trial Use became available in 2017 and the first normative edition is planned for 2018.

Healthcare web services

The FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More standard is based on the following simple five key points:

  1. Faster to learn and implement
  2. Lower cost
  3. Scales well from simple to complex
  4. Flexible
  5. Free

The impact of many of these key points will be seen throughout the following sections.

Comparison to existing standards

HL7 V2

HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More V2 is a well-established standard that works well within institutions to connect applications. However, it is a legacy standard with unique syntaxes, custom tools, and a hefty learning curve for those entering the healthcare IT industry. The design of the standard is also limiting to modern devices and apps that are trying to leverage available patient data. Privacy and security are also difficult to implement. These limitations have become a barrier to patient engagement and making patient data available in the most convenient formats.

Similarities and Differences Between HL7 V2 and FHIR

HL7 V3

HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More V3 was meant to be the successor of HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More V2. It leveraged modern standards technologies available at the time while being based on a reference model, but ended up being overly complex to implement with a steep learning curve. It also had no backwards compatibility with HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More V2, which made switching to the new standard all the more complex given how embedded HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More V2 is within the U.S. healthcare system.

Similarities and Differences Between HL7 V3 and FHIR

HL7 CDA

HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More CDAClinical Document Architecture (CDA) HL7 CDA uses XML for encoding of the documents and breaks down ... More was incorporated into the Meaningful Use criteria, and thus has broad penetration in the United States. However, there remains many drawbacks with CDAClinical Document Architecture (CDA) HL7 CDA uses XML for encoding of the documents and breaks down ... More that are being exposed by the requirements of Meaningful Use:

  • Due to the same complexity as HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More V3, the learning curve is still steep
  • InteroperabilityInteroperability refers to the ability of two or more systems or components to exchange information ... More beyond a human-to-human level is still challenging
  • CDAClinical Document Architecture (CDA) HL7 CDA uses XML for encoding of the documents and breaks down ... More documents do not fit well in many workflows
  • Extensibility is difficult

HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More is developing FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More profiles for Consolidated CDAClinical Document Architecture (CDA) HL7 CDA uses XML for encoding of the documents and breaks down ... More (C-CDA). There are also several projects looking at providing automated transformation between C-CDA and FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More.

Similarities and Differences Between HL7 CDA and FHIR

HL7 FHIR—differentiators

HL7 FHIRFHIR stands for Fast Healthcare Interoperable Resource. This emerging standard combines the best fea... More differentiates itself from past standards technologies by focusing on the following:

  • Focus on those who are implementing the standard
  • Ensure common scenarios are easily supported
  • Leverage cross-industry web technologies
  • Require human readability as base level of interoperabilityInteroperability refers to the ability of two or more systems or components to exchange information ... More, same as CDAClinical Document Architecture (CDA) HL7 CDA uses XML for encoding of the documents and breaks down ... More
  • Make the standard freely available
  • Deliver flexibility by supporting multiple paradigms and architectures
  • Provide for modern governance of data

Focus on the implementers

HL7 FHIRFHIR stands for Fast Healthcare Interoperable Resource. This emerging standard combines the best fea... More was written with implementers as the target audience in mind. Of high importance was the use of reference implementations, which were incorporated into the design of FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More from the beginning. Robust testing was deemed important as well for implementers, which led to the availability of public test servers.

Starter APIs have been made available for a variety of programming methods including C#, Java, Javascript, Objective C, and Delphi. And to allow implementers to test with others along the way, Connectathons were established very early on to verify specification approaches and continue at HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More workgroup meetings.

Support for commonly used workflows

The content in the core specification is meant to cover the top 80% of use cases. This is similar to the focus of the HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More V2 standard, only the extensions will be cleaner and easier. The idea is to focus on the real needs of the industry, but allow for all the special use cases as well. HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More V3 was commonly criticized for trying to account for too many use cases in the core standard, thus leading to an overly complex standard that was difficult to achieve.

FHIR timeline

Embrace web technologies

The use of RESTful web servicesWeb services are a standardized way of integrating applications. Using open standards, businesses ca... More as an API has been on the rise over the last decade across all industries. RESTful web servicesWeb services are a standardized way of integrating applications. Using open standards, businesses ca... More is embraced by organizations such as Facebook, Twitter, and Amazon as their primary API. In addition, related technologies such as XML, JSON, and Oauth, are also common when dealing with encoding and authorization. These technologies have well supported tools and a large talent pool of IT resources. Thus, healthcare will not be locked in to unique industry standards, but can embrace what is used across all industries.

Human readability

The concept of human readability being the minimum level of interoperabilityInteroperability refers to the ability of two or more systems or components to exchange information ... More was introduced with the CDAClinical Document Architecture (CDA) HL7 CDA uses XML for encoding of the documents and breaks down ... More standard. The idea is that if none of the structured data is able to be imported into the receiving system, the data could be viewed in a standard web browser. HL7 FHIRFHIR stands for Fast Healthcare Interoperable Resource. This emerging standard combines the best fea... More continues with this concept to ensure that human readability will always be an option.

Paradigms for packaging the payloadPayload refers to the content of the message being sent (i.e., the message body).

HL7 FHIRFHIR stands for Fast Healthcare Interoperable Resource. This emerging standard combines the best fea... More plans to support four interoperabilityInteroperability refers to the ability of two or more systems or components to exchange information ... More paradigms, which are distinct ways of utilizing FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More to best accommodate varying workflows. The four paradigms and when they might be used are:

  • RESTREST (Representational State Transfer) is a web services approach used heavily in social media sites... More  Small, light-weight exchanges with low coupling between systems
  • Messages  Communicate multiple resources in a single exchange
  • Documents  Focus is on persistence when data spans multiple resources
  • Services  Use a custom service when capabilities of other paradigms don’t fit requirement

Regardless of the paradigm, the content is still based on resources. The resources are just bundled into different data sets depending on the paradigm. The diagram below details some of the key differences among the paradigms.

Definitions of Paradigms

Resources defined

Resources are small, logically discrete units of exchange. Resources define behavior and meaning, have a known identity and location, are the smallest possible unit of transaction, and provide meaningful data that is of interest to healthcare. The plan is to limit resources to about 150 in total. They are sometimes compared to an HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More V2 segment.

The resources can be extended and adapted to provide a more manageable solution to the healthcare demand for optionality and customization.

FHIR Resources

Modern governance

Governance to maintain the privacy and security of patient data will be of utmost importance to the success of FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More. FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More includes modern capabilities that should allow policies to be constructed in a way that are protective but not constraining.

All exchange of production data is expected to be secured using TLSTLS (Transport Layer Security) is a successor to SSL and offers increased security. See also: S... More/SSL. Authentication can be achieved in a number of ways, but OAuth is recommended for web-centric use. FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More defines a Security Label infrastructure to support access control management, and FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More also defines provenance and security event resources suitable for tracking the origins, authorship, history, status and access of resources.

FHIR Emerging Standards: XML (Encoding Data), REST (Communication), and JSON (Encoding Data).

Where might HL7 FHIR be used?

HL7 FHIRFHIR stands for Fast Healthcare Interoperable Resource. This emerging standard combines the best fea... More has the capability to be used in a variety of workflows, from small mobile devices to large multi-facility hospital information systems. FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More not only enables new workflows, such as those related to patient engagement, but also more traditional communications between applications.

Common workflows include:

  • Traditional application-to-application interoperabilityInteroperability refers to the ability of two or more systems or components to exchange information ... More within the four walls
  • External connectivity
    • HIEs / ACOs
    • National exchanges
    • Social web
    • Mobile applications
    • Home health devices

The timeline diagram in Image 4 depicts potential FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More workflows.

Potential FHIR Workflows

  • Initially, there will likely be a need for broker applications, such as an interface engineAn interface engine can transform or map the data to the receiving application’s requirements whil... More, to act as middleware between applications that still use traditional standards and those with the new FHIR-based standard.
  • Patient engagement will be a major target for FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More. Apps will be able to leverage the lightweight RESTREST (Representational State Transfer) is a web services approach used heavily in social media sites... More standard to provide patients timely data and alerts.
  • FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More will also be utilized as a link into patient data repositories, where applications all throughout the provider facility can gain access to patient data only when the patient shows up in their department.

The diagram in Image 5 expands on the third scenario in Image 4, patient data repository access.

Patient Data Repository Access

Many departmental applications throughout the provider facility will query the FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More database repository for the data they need, when they need it, allowing for very efficient data transfers and an accurate single source of truth for all data.

Advances in FHIR

SMART 

The HL7 FHIRFHIR stands for Fast Healthcare Interoperable Resource. This emerging standard combines the best fea... More standard can be used for a variety of workflows, as illustrated in the previous section. However, the key step in enabling the FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More technology is to have major vendors open up their clinical data in a FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More repository so other applications can leverage it to solve creative workflow problems. In addition to having the data available, there is an emerging technology that would take this even one step further. The technology is called SMART, and it allows more robust functionality and creative usage of the data directly within the EHRElectronic Health Record (EHR), as defined in Defining Key Health Information Technology Terms (The ... More itself. SMART on FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More would embed third party functionality directly within the EHRElectronic Health Record (EHR), as defined in Defining Key Health Information Technology Terms (The ... More application itself. In a nutshell, SMART enables third party plug-in apps to run natively inside any compliant EHRElectronic Health Record (EHR), as defined in Defining Key Health Information Technology Terms (The ... More.

The SMART project started in 2010 with a fouryear, $15 million grant from the ONCOffice of the National Coordinator for Health Information Technology (ONC) – Located within the Of... More. The idea was to build an app platform for healthcare allowing support apps to be chosen by clinicians. Each year at the HIMSS InteroperabilityInteroperability refers to the ability of two or more systems or components to exchange information ... More Showcase, several vendors demonstrated the progress they are making by incorporating SMART. Since then app development has proliferated, and there are currently 44 apps available on the SMART web site. All the apps use the same underlying set of platform specifications. The SMART specs provide means for health care organizations or developers to access discrete clinical data—such as medications, problems, lab results, immunizations and patient demographics.

SMART opens up innovation in healthcare like has not been possible previously. If someone has a bright idea to enhance workflow and creates a SMART app, the healthcare provider doesn’t need to wait for an EHRElectronic Health Record (EHR), as defined in Defining Key Health Information Technology Terms (The ... More vendor to adopt the idea. Assuming they have a SMART-compliant EHRElectronic Health Record (EHR), as defined in Defining Key Health Information Technology Terms (The ... More, they can immediately take advantage of the bright idea through the use of the app.

The ArgonautThe Argonaut Project addresses the recommendations of the JASON Task Force, a joint task force of th... More Project

ArgonautThe Argonaut Project addresses the recommendations of the JASON Task Force, a joint task force of th... More is a supporting movement of FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More in the U.S. led by volunteers. Individuals within HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More were focused on keeping the FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More project on target with its self-proclaimed deadlines for adoption. This focus was especially important considering the Open API requirements for Meaningful Use Stage 3. Several of the major EHRElectronic Health Record (EHR), as defined in Defining Key Health Information Technology Terms (The ... More vendor organizations also wanted to do what they could to help push development and adoption in the U.S. So HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More, along with these vendor organizations, set out to do two things through the ArgonautThe Argonaut Project addresses the recommendations of the JASON Task Force, a joint task force of th... More Project: First, they funded the work to build a U.S. specific profile, and second they combine resources to help market and drive adoption of the standard.

The organizations are working with HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More and the ONCOffice of the National Coordinator for Health Information Technology (ONC) – Located within the Of... More to shed light on the best way to use FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More in the U.S. considering there are some parts of FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More that are very international in perspective. For instance, because there is no consistency around the world with how medication is encoded, FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More doesn’t make any rules about how medication is encoded. But in the context of the U.S., RxNorm is the coding system used for medication. HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More is working through many similar types of issues with the ArgonautThe Argonaut Project addresses the recommendations of the JASON Task Force, a joint task force of th... More members. This will hopefully help drive a cleaner more consistent standard for the U.S., along with a speedier adoption due to the buy-in of the larger vendor organizations that are participating.

Where does FHIR go from here?

The industry is waiting to embrace a standard that offers something better, but given the embedded nature of HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More V2, the transition will not happen overnight. FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More tries to fill the gaps that exist with the standards in use today, as has been discussed in this paper. While the healthcare market will decide whether FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More survives, coexists, or replaces other products, the modern technologies that it is based on have already won over other industries.

Additionally, other standards organizations are jumping on board to support HL7HL7 is a Standards Developing Organization accredited by the American National Standards Institute (... More in the development of FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More. One of those is IHEIntegrating the Healthcare Enterprise (IHE) is an initiative by healthcare professionals and industr... More International, which plans to leverage FHIRAn HL7 standard that is short for Fast Healthcare Interoperability Resources and pronounced “Fire... More across several profiles including: MHD (mobile XDS), PIXm/PDQm (patient identification), PCC (care coordination), mACM (alerting), and others

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