Five Challenges to Interoperability that FHIR can Extinguish
By George Morris, vice president of software engineering
Fast Healthcare Interoperability Resources or FHIR (pronounced “fire”) is a standard sponsored by Health Level-7 (HL7) that will attempt to enable community-wide interoperability for a more cost efficient system, and more importantly, will help to improve patient outcomes. But as you probably know, interoperability in the healthcare system is facing major challenges. Here are some thoughts on the challenges facing the industry today, and how FHIR may help to extinguish these challenges:
1. Silos Continue to Roadblock Interoperable Systems
I recently visited my Primary Care Physician (PCP) and he ordered some lab work for me. He gave me a sheet of paper with the order and another sheet of paper with a list of locations I could go visit. When I visited the lab they knew nothing of my medical records nor were they able to send the results back to my PCP except by fax. Fax. In 2015. Fortunately I didn’t need to visit the hospital, but if I had to, they too would not have had access to any of my medical records because of their own silos of information located within their Electronic Health Record (EHR) system.
2. Interoperability is Complicated by Too Many Standards
The state of healthcare in America today lags behind the adoption of technology in other industries, and more specifically with interoperable systems. Why is it this way? One of the issues is with standards. Andrew Tanenbaum once wrote, “The nice thing about standards is that you have so many to choose from.” Healthcare has many different standard bodies to choose from; however each promulgates their own interfaces, which complicates interoperability.
3. EHRs Have Had a Lack of Incentives
In the past, EHR vendors have had little incentive to deliver interoperable systems. This is because their ideal solution is to provide a single EHR, across all locations, nation-wide (unsurprisingly their own EHR).
4. The Lack of Interoperability is Increasing Costs and Decreasing Quality
This lack of interoperability directly affects healthcare costs as well as patient care. As I noted from my own personal experience, my medical records could not be shared among my PCP and the laboratory I visited. At a minimum, this can lead to inefficiencies in my healthcare, i.e. the same lab tests may be ordered or multiple prescriptions may be provided of the same drug. At the very worst, the lack of interoperability can lead to patient safety issues, i.e. drug–drug interactions, if multiple physicians are unaware of prescriptions being made outside of their EHR system.
5. Software Standards are Still Difficult to Implement
Current healthcare software standards are difficult to implement, which leads to a lowest common denominator approach (HL7 version 2 being this lowest common denominator). While HL7 version 2 is widespread across the industry, it is based on a 25-year-old technology that is specific to healthcare. Unfortunately, this means that any software advances in the industry cannot be applied here. HL7 standards are also commonly customized by healthcare systems which make it challenging to interoperate. HL7 version 3, Reference Information Model (RIM) and Clinical Data Architecture (CDA) were developed as attempts to address these concerns. However these ended up being very difficult for software vendors to implement.
How FHIR Can Extinguish These Challenges
FHIR posits the following manifesto to avoid the pitfalls of previous standards:
- Focus on implementers not modelers
- Keep common scenarios simple
- Leverage existing technologies
- Provide human readability
- Support multiple paradigms
- Make content freely available
The basic concept of FHIR is the use of resources, which are discrete units of information, that have a known identity and location, much like how a URL of a picture defines its location within the world wide web. The atomic nature of FHIR resources along with the use of standard web technologies makes the exchange of information easier and more targeted, therefore providing an optimal environment for achieving community-wide interoperability to reduce costs and improve patient outcomes.
Is your future focused on FHIR?
 Tanenbaum, Andrew S. (1988) Computer Networks, Second Edition.  Kramer, Ewout (March 14, 2013) FHIR: The Basics (and beyond), Slide 10.