How Fast Interoperability is Speeding Innovation in Healthcare

Healthcare leaders at Boston Children's Hospital, DukeHealth, and Intermountain Health find that Fast Health Interoperability Resources aids in the flow of discrete data and clinician workflow.

This article first appeared in the June 2016 issue of HealthLeaders magazine.

An unlikely trio—a children's hospital, an academic medical center, and a regional hospital system just converting from a home-grown enterprise EHR to a commercial one—is blazing a trail that is beginning to allow data to flow in discrete bits to spur innovation and interoperability across all of healthcare.

The three—Boston Children's Hospital, DukeHealth, and Intermountain Healthcare—are among the first in the nation to implement new HL7 technology known as Fast Health Interoperability Resources, or FHIR, not just for new patient data access options, but to enhance clinician workflow and decision support.

On the patient data access front, a fourth player, Hackensack University Medical Center, part of the four-hospital, 1,717-licensed-acute bed Hackensack University Health Network, was one the first implementers of FHIR, with its own patient-facing app interfacing with the Epic EHR, late last year.

"We are requesting and encouraging vendors to adapt to FHIR, or it will become difficult to work with Hackensack," says Shafiq Rab, MD, vice president and chief information officer of Hackensack UMC.

One element of the Centers for Medicare & Medicaid Services' EHR incentive program updated in October 2015 is spurring interest and development in FHIR and other application programming interfaces (API). According to CMS, requiring 2015-certified EHR software to support these APIs will "enable the development of new functionalities to build bridges across systems and provide increased data access. This will help patients have unprecedented access to their own health records, empowering individuals to make key health decisions."

Even though such certified software will not be required to be in use until 2017 at the earliest, EHR vendors such as Cerner, Epic, and others have already implemented several FHIR interfaces in the EHR software they are currently shipping, with more interfaces, known as FHIR resources, being added throughout this year.

Fundamentally, FHIR allows developers to query, fetch, and potentially update discrete data elements from EHRs. Prior to FHIR and other API approaches, developers had to deal with less granular Consolidated Clinical Document Architecture (C-CDA) formatted data, creating application development and privacy challenges, says Josh Mandel, lead architect at Boston Children's Hospital and Harvard Medical School.

In addition, HL7 made the FHIR specification freely available—a change from the days when downloading the C-CDA specification required that fees be paid to HL7, Mandel says.

At Boston Children's, Mandel's initial focus, which predated FHIR, was a project called SMART, which stands for Substitutable Medical Applications and Reusable Technologies. SMART is a method to create applications to be written once and run unmodified across different healthcare IT systems, capable of being launched from an EHR, and bringing information from that EHR, such as a patient's demographics, into an app that extends the capabilities found in the EHR.

"There was a real disconnect between what we needed to do as clinicians and what the systems were set up to allow us to do," Mandel says.

In 2010 the HHS Office of the National Coordinator for Health Information Technology funded $15 million over four years to develop SMART. In 2013 Boston Children's updated SMART to take advantage of HL7's FHIR standard, including its data model representation of EHR and other health IT data as FHIR resources. The result: Application development accelerated.

"Rather than focusing on low-level data, we decided to focus on the user experience" of running SMART on FHIR applications, some of which present themselves to users as part of the overall EHR experience, and others of which can run in the background, querying and updating EHRs or other healthcare IT interfaces such as analytics dashboards, Mandel says.

SMART on FHIR is architected to allow developers to swap out one app for another if the newer app is superior, he adds.

"The story is not as simple as saying your vendor will give all this to you, and the new features will just roll out and you won't have to negotiate for them and you'll just have all this," Mandel says.

"Early on, it's going to be those organizations that understand the value and are willing to push for it, that will benefit first."

Mandel also describes an emerging project called Clinical Decision Support (CDS) Hooks, which is designed to extend the application model with deeper workflow integration.

"For any service that fits naturally into an EHR workflow at a specific point, CDS Hooks gives us a way to augment the EHR, so that when you're doing a particular task in the workflow, like prescribing a new drug, then you can automatically call out to FHIR-enabled services and see whether or not they have anything relevant to recommend," Mandel says.

"We were very similar to many of our Boston-based counterparts in that we were very much an in-house development kind of shop, where we had a few commercial systems in place, but a large portion of what we did was done using self-development," says Daniel Nigrin, MD, senior vice president and CIO of 398-licensed-bed Boston Children's.

"Although commercial systems are meeting our needs quite well now, there are still pockets where they're not, and where there's frankly just missing functionality that we feel compelled to try to make efforts to get into our EHR."

One of the first SMART on FHIR applications was the pediatric Growth Chart app developed at Boston Children's. The physician decision-support app uses patient demographics such as gender, date of birth, and available height, weight, head circumference, and body mass index data to plot growth against norms developed by the Centers for Disease Control and Prevention, the World Health Organization, and other disease-specific statistical norms.

As a sign of SMART on FHIR's appeal, the first healthcare system to put Boston Children's Growth Chart app into production use was 2,100 miles west, at Intermountain Healthcare, a 22-hospital system based in Salt Lake City, which recently converted from an in-house EHR to Cerner.

"It was a demonstration app at Boston Children's, and when we made it a production app, we had to do a lot of work," says Stan Huff, MD, chief medical informatics officer. By modifying the source code of the app, Intermountain was able to allow for periodic updates in the growth chart calculations as published by WHO and other organizations, he says.

Another tweak considered gestational age at time of birth, which Huff says growth charts need to know to make proper recommendations. Because Boston Children's published the app under an open source software license, Intermountain's refinements get incorporated into the code base and benefit all future users of the app, he adds.

Intermountain is using SMART on FHIR as a jumping-off point for its own industry initiative to add even more intelligence to the way applications talk to each other, Huff says. For instance, FHIR does not express some potentially important data about blood pressure, such as where on the body it was measured, or whether the patient had just been exercising or was at rest.

To advance this work, in 2014, Intermountain formed the Healthcare Services Platform Consortium (HSPC), which is incorporating work from the Clinical Information Modeling Initiative, also formed by Intermountain, to create what Huff describes as "very detailed information models" to express even richer data exchange concepts that may be brought forward into FHIR through the use of FHIR profiles, Huff says.

"These are a set of information models that are the basis for true interoperability," he says.

"When you create an application, you need to declare which of these information models, which of these FHIR profiles, your application is compliant with. And then you need a way to actually test that." Huff notes, however, "we need more experience to know whether in fact I'm creating too complex a model and worrying about problems that don't actually exist."

SMART on FHIR applications will also soon find their way into app stores being developed or already in operation by EHR vendors.

"I think Cerner and Epic, even though this thing has been certified as being FHIR-compliant and HSPC-compliant, are planning to put it through their own QA and say, 'OK, and we're going to add one more stamp on this thing that says this thing runs and is a good member of the community; it doesn't bring our system down,' " Huff says.

There are also time and other pressures on Intermountain and other providers to continue to use existing proprietary EHR tools to add functions. "I would build everything as a SMART on FHIR app, but the reality is that building things within the known Cerner tool set is a much more predictable time frame and a much more predictable process, and so things that are on the critical path for us to go live, there is a tendency for us to build in the old way," Huff says.

"As we get more experience and become more predictable, we hope we'll get more and more things that are being built in the new way."

DukeHealth, whose Duke University Hospital has 957 beds, is another healthcare system that has adopted SMART on FHIR for clinical use. In mid-2014, DukeHealth built a prototype application on top of the Epic EHR, an application that allowed connecting an Android-based mobile app that could pull demographics, medication lists, and problem lists from Epic into the mobile app, Ricky Bloomfield, MD, director of mobile technology strategy and an internal medicine pediatrics physician at DukeHealth, says.

"This was all before we really became aware of FHIR and SMART and all the work that was going on at Boston Children's," Bloomfield says.

"Our ultimate goal was simply to create something that would allow us to better interface with the EHR in standards-compliant ways, and we did not care at all if we were the ones to do it, and so we immediately reached out to them and basically took the work that we had already done, and it was fairly trivial to modify it to be FHIR-compliant because we were already using the same underlying technologies."

One DukeHealth-developed app that made the leap to SMART on FHIR last year was Duke Pillbox, which trains patients in the correct dosage and frequency of prescribed medication.

The app pulls medication data via FHIR from the Duke Epic EHR, then associates that data with images of the actual medications. Although currently in use in several research studies, the goal is to deploy the app both as part of the discharge process and for use in the patient's home.

During a hospital discharge process, for example, the app, running on an iPad®, challenges patients to drag and drop medication dosages into boxes labeled morning, noon, afternoon, and evening. "The app grades patients on how accurately they do that," Bloomfield says. The app records the process so nurses can play the interaction back and see where patients had difficulties, he adds.

As of last September, DukeHealth is also running Boston Children's Growth Chart app in production with its EHR, which also proves another of FHIR's strengths as a standard: its ability to enable apps to run essentially unchanged on multiple vendors' EHRs.

Duke is currently involved with a multivendor, multiprovider HL7 initiative to implement the meaningful use Common Data Set as a set of SMART on FHIR resources, an initiative known as the Argonaut Project.

SMART on FHIR is also stepping up to nationwide calls to implement precision medicine objectives in software.

Duke is leading a study funded by the National Genome Research Institute that has produced an app called MeTree, a patient-facing risk assessment tool that collects personal health information and family health history. "Once development of MeTree is complete, then that information can flow directly into Epic using FHIR," Bloomfield says.

Providers also believe FHIR offers easier ways to connect data silos between their own internal health IT systems, as more and more of those systems implement interfaces to FHIR. In part, this is because developing FHIR interfaces is less like developing technically challenging HL7 version 2 interfaces and more like building applications for Web services such as Facebook and Google, says Boston Children's Mandel.

"Engineers with backgrounds in developing Web technology have what they need to build an FHIR server," he says.

"We believe wholeheartedly in ensuring that you're able to abstract data out of these silos of repositories that healthcare organizations are so used to going live with," says Rasu Shrestha, MD, chief innovation officer at Pittsburgh-based UPMC, which operates more than 20 academic, community, and specialty hospitals. Shrestha is also executive vice president of UPMC Enterprises.

"The future of care delivery really needs to be dictated not by a vendor but more by the clinical needs that we have in an organization like UPMC," he says.

"We've been doing a lot of work in terms of analytics, pulling data together in an enterprise data warehouse so we can connect across clinical data and claims data. What you really need is a way to more easily abstract the data out of this lake that you've created."

Toward that end, UPMC, which runs EHR software from multiple vendors, is working on REDA, which stands for Real-time Enterprise Data Abstraction, a layer of code to FHIR-enable all data and apps at UPMC to permit development of apps for precision medicine, healthcare IT, and more, Shrestha says.

"Right now we're not looking to commercialize this," he says. "This is our attempt to abstract the data we own and have access to."

Part of FHIR's journey to all corners of healthcare will also be to manage expectations amid a wave of hype. For instance, none of the providers interviewed is expecting FHIR to replace years of operational HL7 version 2 interfaces in use throughout healthcare IT.

"I don't think the intent of FHIR was to enable interoperability between many large systems," Bloomfield says. "HIEs have been created to do that. But what it does do is standardize the interactions of specific apps and widgets with EHRs. At least I think that will be the majority of initial use cases that we see."