Author: Duncan Weatherston, CEO, Smile CDR.
A Technology Perspective for the FHIR Community
In Fast Healthcare Interoperability Resources, or FHIR, healthcare has finally found a technology that can usher in its long-anticipated internet moment. By introducing a web based way for diverse participants to exchange data and ideas about healthcare, FHIR will enable an open standard ecosystem of services that will fundamentally shift how healthcare is delivered. The FHIR community is at the vanguard of this impending digital disruption to healthcare.
Why the Healthcare Industry Needs to Change
The healthcare industry has certainly made efforts to engage in digital transformation, in much the same way that its peers in banking, manufacturing, logistics, and retail have done. And yet, the relationship between healthcare and the internet has remained largely peripheral.
Although we’ve seen substantial growth in the uptake of electronic health records, very little has changed in the way medical professionals diagnose, treat, and interact with their clients. For many, IT tools are viewed as, at best, merely another administrative burden or restrictive and limited resource, and at worse, a hindrance to proper, old-fashioned, face-to-face patient care. And it’s hardly surprising as, so far, information technology solutions have often failed to live up to their promises for the industry. In fact, proliferation of EHRs physicians has been linked to longer working hours for clinicians, increased stress levels, and ultimately a greater risk of burnout. What’s more, the critical data within EHRs remain disconnected and siloed.
To date, little change has been realized for the healthcare sector in terms of organizing, storing, and sharing information, let alone the lofty aspirations of AI-based solutions for proactive patient care and diagnoses. New technologies and applications do have the potential to reshape healthcare, but that progress will be limited if each new technology results in a new data silo. New applications badly need the ability to share the information they collect in a modern way; however, under the current patchwork of proprietary data models and disconnected systems they’re too often introduced as yet another walled garden.
But if the pandemic has taught us anything, it is that healthcare is in dire need of a shake-up. The emergence of COVID-19 on the world stage challenged healthcare systems around the globe, as hospitals were overrun with patients and undersupplied in equipment, PPE, and clinicians. Reaching far beyond the effects of the virus itself, the pandemic has resulted in the upheaval of everyday healthcare for all patients. Popping into your GP or making an emergency trip to the hospital is no longer the solution it once was for most of North America or, for that matter, the world.
Thankfully, FHIR and the Internet of Health represent a technological solution that will better equip us not only for the everyday care of patients but for the emergence of potential future pandemics. The technological innovations proposed by FHIR will mean true interoperability for the healthcare sector and, in real terms, mean the more effective exchange of patient data, for enhanced diagnostic and treatment capabilities that have the capacity to be widely—if not universally—adopted throughout the industry and across the globe.
Why the FHIR Community Must Build the Internet of Health
The foundational truth of the Internet of Health is this: in order for anything to be a broadly adopted and broadly successful pattern of behaviour, it requires comprehensive uptake from the community, and for multiple parties to participate in order to ensure adequate incentives of engagement and by extension, profit for developers. Further, this uptake and adoption ultimately needs to be driven by communities realizing value with a suite of technologies that enable them to be part of a greater whole—not simply because they’ve been mandated to do so. By using FHIR and building IGs communities of interest contribute to the Internet of Health. Crucially, these new contributions (and the services they enable) won’t result in more silos, but a connected ecosystem of lanes through which health information can flow.
In order for us to achieve the complexity and engagement necessary for the success of the Internet of Health, we—the FHIR community—must support the idea of heterogeneity and diversity in the creation of capabilities. This means we must encourage healthy competition amongst community members. Crucially, to generate the kind of optimism required for broad adoption of the “new world view” of the Internet of Health, there must be a solid framework for the exchange of information and ideas.
In the healthcare sector, we are concerned with data about people’s health, medications, patient outcomes, services available, capabilities of organizations, and more. The breadth of the exchange of information required by the Internet of Health could be likened to a semantic map of the services and capabilities of the healthcare sectors as a whole. In order to succeed, the Internet of Health requires useful implementation guides (IGs) to be built so that leading ideas can emerge and, where useful, find widespread adoption. Agreement on standards encompases areas as diverse as terminology, care plans, billing standards, accreditation, and validation. This agreement occurs in a de facto manner, and follows adoption and demonstrated value. In other words, elements of any specification need to prove their worth in live environments before they’re added to the standard. That effort necessitates an unprecedented level of collaboration as well as competition. And that is where the FHIR community plays a critical role.
How the FHIR Community Will Build the Internet of Health
For the Internet of Health to be successful, the FHIR community must find innovative ways to leverage this rich standard. A key strength of FHIR is that it allows for further collaboration and elaboration to occur organically over subsequent versions of its iterations. A key focus of FHIR has always been to create a standard that is implementable, so engagement with developers actively building and implementing healthcare software is central to FHIR’s success. New features are submitted and rigorously tested by the implementer community at FHIR Connectathons which take place around the world. In this sense, FHIR builds on lessons learned from previous standards through its emphasis on ease and speed of adoption.
This ethos is further reflected in the many open source projects used by and built with input from the FHIR community, such as Smile CDR’s own open source product, HAPI FHIR. As the most widely deployed FHIR server in the world, HAPI FHIR is constantly stress-tested by its community of users who help drive its development by contributing ideas, roadmap items and even code. They also use HAPI as a platform for building innovative FHIR applications, adding yet more value.
One of the key ways in which FHIR is primed for establishing the Internet of Health is that it gives users the ability to create IGs, and to create communities that are responsible for those IGs—much in the same way that Internet Request for Comments (RFCs) did in the early days of the internet. FHIR gives users the ability to propose extensions to the standard itself so that the resources necessary to fulfill capabilities to extension guides can be added to the canonical level of the FHIR spec. The participation of the FHIR community is therefore critical to the success of the Internet of Health as a collective and connected suite of services. Indeed, the most widely adopted FHIR IGs, like the US Core Data for Interoperability, the Da Vinci Project's IGs, and the CARIN Group’s Blue Button IG are all communities built on processes, infrastructure and testing methodologies pioneered by the broader FHIR community.
IGs are a perfect parallel to RFCs in the development of the internet in its infancy, in that recommendations can be made for implementations and expansions, and these recommendations can be easily implemented, thanks to the FHIR standard. Crucially, to ensure maximum efficacy for the healthcare sector, there is no need for users to implement a standard that they do not want or need. The choice is made instead by considering two factors only: is it effective and is it necessary? This realization of value is what will drive—on a fundamental technology level—the adoption of FHIR in the same way that the internet was so universally embraced. Because users are not forced to adopt “everything or nothing” as with other types of standards, and are not being forced to play by one vendor’s set of rules, the freedom to realize the true value of the Internet of Health means an exciting proposition for every player in the industry. Each and every stakeholder is offered a smorgasbord of ideas, of which the best will be widely adopted, and yet those less popular are still available to be implemented by those who may find them useful. This is the strongest and most enduring element of this effort, and the one that will ultimately establish the success of the Internet of Health, as it did for the internet.
The FHIR Business Alliance, or FHIRBall, represents a collaborative effort we can liken to that which would go on to facilitate and power the internet as we know it today through the TCP/IP standard. This not-for-profit organization is actively engaged in the expansion and development of the FHIR standard and each of its collaborative partners subscribes to the core value that “every healthcare organization and patient deserves the best that technology has to offer.” A collaboration between actively engaged FHIR community members, FHIRBall is committed to the business values of healthcare data belonging to healthcare organizations and patients, and the use of open standards to use open APIs to access data.
There are no shortage of challenges that arise in both the clinical and administrative spaces in healthcare around tracking the relationships between people, observations, billing, outcomes and more. And as such, we know that our community will find innovative ways to make use of the resources developed within FHIR. Doubtless, going forward, numerous IGs will be rolled-out and implemented, which will subsequently have products built around them. This is where the FHIR community will be at the forefront, and the group of firms involved in FHIRBall, who are equally collaborative and engaged for the advancement and betterment of society and coming from the open standards perspective, will be invested in a unique vision for how each of these emerging ideas is deployed to their clients and realized as services. Success will be driven by the notion that parties will be competing to implement things that are neither proprietary nor trivial. There is a strong business case to be made for the rapid adoption, creation, and deployment of capabilities and subsequent further development as the guides are extended.
The critical factor in driving the FHIR standard Internet of Health is each of the members of the FHIR community, and competition between FHIR community members is a key to the success of the standard. As we have seen in the past with TCP/IP and the internet, the success of a standard doesn’t hinge on individual implementations, but on collective adoption and widespread use. The broad community involved in the development of the FHIR standard fosters friendly, healthy competition and collaboration for the ultimate benefit of all. Our real competitor is not a rival FHIR community member, but rather the status quo.
Here at FHIRBall, we are united behind a common cause and leading the revolution in healthcare that we will soon see adopted across the sector. The FHIR community, and FHIRBall members in particular, are primed to facilitate the advent of the Internet of Health to deliver value to businesses, patients, and the healthcare sector at large.
Read Part 2: Why Collaboration Matters for the Internet of Health
Read Part 5: How Smile CDR is Enabling the Internet of Health