Explaining FHIR

Historically, the healthcare industry has faced significant challenges in data exchange, often due to proprietary technologies and concerns about data privacy. However, rapid changes are underway, and a key factor in this evolution is interoperability, which refers to the ability of different healthcare systems to communicate and exchange data effectively.

This article aims to provide a gentle yet comprehensive introduction to the world of healthcare interoperability, focusing on HL7 and FHIR, and their implementation in India. We’ll delve into what these standards are, why they’re important, and how they’re transforming healthcare data exchange.

Introduction to HL7

Health Level Seven International (HL7) is a leader in healthcare technology that focuses on seamless data exchange in healthcare. It develops international standards for sharing and integrating clinical and administrative data across different applications.

Essentially, HL7 allows various healthcare systems to ‘speak the same language’. The standards operate primarily on the application layer of the OSI model (layer 7). They support multiple aspects like clinical practice, management, delivery, and evaluation of health services.

Recognized worldwide, they are some of the most widely used standards in healthcare. When a hospital or clinic decides to use HL7, they’re basically agreeing to use this common language. It might take some work to set it up, but it’s like learning to ride a bike — challenging at first but very useful in the long run.

Understanding FHIR

Created by HL7 in 2014, Fast Healthcare Interoperability Resources (FHIR, pronounced “fire”) is a modern standard that builds upon and enhances the capabilities of previous HL7 standards​​. At its heart, FHIR uses data formats and elements known as ‘resources’, along with an Application Programming Interface (API) to facilitate communication.

One of the standout features of FHIR is its flexibility and adaptability, suited for various settings and healthcare systems. Its widespread use in the industry includes mobile app data access for clinicians and integration of electronic health records (EHRs) into decision support services.

Components of FHIR

FHIR is built on several core components, each playing a crucial role in its functionality. Let’s explore these:

Resources

Resources are the foundational elements of the FHIR standard, often referred to as its “building blocks”. Each resource is defined by its specific context and contains standardized healthcare information. A patient resource, for instance, includes details like name, address, telephone number, allergies, and medical condition. This standardization ensures that when two FHIR-based systems exchange data, they can seamlessly integrate and interpret the data without the need for additional tweaking or data conversion​​.

Profiles

FHIR adheres to the 80/20 rule, where it aims to cover about 80% of the data elements in healthcare systems. The remaining 20% can be adapted for specific use cases. This is achieved through profiling, which involves extending or constraining elements in the base resource. Profiles allow for the customization of resources to suit specific needs and contexts. They define missing extensions and dictate how API functions and terminologies should be used. Profiling is essential for adapting FHIR to various healthcare scenarios​​.

Implementation Guides

IGs are collections of FHIR resources, including profiles, value sets, examples, and documentation. They provide specific rules and guidelines on how to use FHIR resources in particular clinical contexts. IGs guide users on which patient attributes should be filled in to comply with national standards or which terminologies to use, ensuring that FHIR is effectively tailored to specific healthcare requirements​​.

FHIR in the Global Context

FHIR has made significant strides in the global healthcare sector, becoming a key standard for health data exchange. It is part of a shift towards open, cloud-based healthcare systems. Universal adoption of FHIR, combined with APIs and open technology, will facilitate data exchange across diverse platforms, enhancing healthcare capabilities​​.

The FHIR Lab at Columbia DBMI is a center of excellence focused on using FHIR in research to improve patient-centered care and care coordination. It serves as a collaborative community for learning and activism around this technology​​​​​​.

In late 2022, the CMS Interoperability and Patient Access Rule and the 21st Century CURES Act mandated all medical records to be accessible via FHIR.

More recently, HL7 and World Health Organization entered a Project Collaboration Agreement, an initiative that aims to support the global adoption of open interoperability standards, including FHIR. The partnership will help integrate WHO’s classifications and terms into the HL7 FHIR community, while also working on creating interoperability specifications that can be used globally but adapted to local needs.

Additionally, this collaboration is set to accelerate progress towards Universal Health Coverage by enabling equitable development and access to foundational elements for digital health.

Overview of FHIR in India

Most experts attest to the fact that the Indian healthcare IT industry has been reactive rather than proactive in adopting interoperability standards. While there is no shortage of technical skills, the lack of regulatory endorsement and provider insistence has hindered progress. Past efforts have been fragmented, and the regulatory approach has fluctuated, creating uncertainty for vendors​​.

However, efforts are ongoing for the localization of standards and India-specific profiling of data models. Indian chapters of standards organizations like HL7 have focused on training for healthcare interoperability standards applicable in developed markets, particularly the USA. The National Resource Centre for EHR Standards (NRCeS) is working to raise awareness and drive participation of the Indian vendor community in these efforts​​.

In fact, HL7 India even organized the first virtual FHIR Connectathon in India, focusing on a ‘COVID teleconsultation Track’. This event indicated a growing interest and willingness in the Indian healthcare community to adopt FHIR for practical and long-term benefits. There is an increasing alignment of political views and a recognition of the opportunities that interoperability opens up, especially for Indian startups​​.

Challenges and Considerations

Finding specific case studies of successful FHIR implementation in India is challenging. This isn’t surprising; implementing FHIR involves considering several key aspects to ensure its success. Let’s delve into some of these critical issues:

Data Quality and Standardization

To address this, it’s essential to establish data governance policies and procedures. This involves defining data standards, implementing data validation processes, and conducting data cleansing activities.

Legacy System Integration

Organizations may adopt middleware solutions or interoperability platforms acting as intermediaries between legacy systems and FHIR. These solutions facilitate data format translation, enable mapping between different data models, and ensure seamless integration with FHIR applications​​.

Security and Privacy

Adhering to industry best practices for secure FHIR implementation is crucial. This includes using secure communication protocols, implementing authentication and authorization mechanisms, and encrypting data. Compliance with relevant privacy regulations is also necessary to ensure data privacy​​.

Scalability and Performance

Addressing scalability and performance involves conducting capacity planning and performance testing, assessing system capabilities, optimizing resource allocation, and leveraging cloud-based solutions for scalability when necessary​​.

Workflow and Change Management

Comprehensive change management strategies, including stakeholder engagement, training programs, and ongoing support, are essential. Preparing clinicians and staff members with the necessary knowledge and resources will facilitate a smooth transition to FHIR-enabled workflows​​.

Additional Challenges Identified

• Slow Adoption
  The healthcare industry’s risk-averse nature means that not many providers promote innovation actively. FHIR’s adoption might be slow due to the time it takes to reach maturity and be incorporated into regulations.

• Cost of Adoption
  Large organizations might face challenges in aligning their existing domain models with FHIR’s concepts. Additionally, the disruption of existing interoperability frameworks can delay the realization of benefits.

• Potential Threats for Vendors
  FHIR might compromise some IT vendors by shortening deployment times of significant systems, which could reduce revenue. Additionally, inconsistencies in FHIR API implementation by EHR vendors can undermine the goal of achieving interoperability​​.

The right strategy for FHIR implementation is crucial for healthcare organizations to unlock its full potential. This involves looking beyond initial compliance pressures and accommodating complex use cases that require more partnerships, connections, and time​​.

References and Further Reading

🔹 FHIR Fact Sheets | HealthIT.gov
🔹 Healthcare’s Guiding Light: How FHIR is Ushering in a New Era (hitconsultant.net)
🔹 FHIR Lab Designed To Create Greater Opportunities For Research; 2023–24 Dates Announced — Columbia DBMI
🔹 HL7 FHIR-based tools and initiatives to support clinical research: a scoping review | Journal of the American Medical Informatics Association | Oxford Academic (oup.com)
🔹 HL7 FHIR | NRCeS
🔹 Healthcare #Interoperability on #FHIR: A Collaborative Open Source Project for #Teleconsultation during #COVID19 pandemic by Aniruddha Nene, NCII — The Healthcare IT Experts Blog (hcitexpert.com)
🔹 Federal Officials Urge Healthcare Industry’s Adoption of FHIR for Interoperability | HealthTech Magazine
🔹 HAPI FHIR: A Limited & Complete Guide for 2023 — CapMinds