In the context of healthcare, interoperability is the ability of different information systems, devices and applications to access, exchange, integrate and cooperatively use data in a coordinated manner. Effective interoperability must work within and across organisational and geographical boundaries, to provide timely access to, and seamless portability of, information. 

To be useful, interoperability must help optimise workflows and software systems for the health benefit of individuals and populations globally.

As an overarching purpose, interoperability must allow for information to have consistent meaning as it moves between people, organisations and systems. 

Data interoperability is a pressing concern for healthcare providers and vendors. To exchange information seamlessly requires standardised protocols allowing disparate systems to share and understand data. In healthcare, a modern such standard, gaining traction fast, is Fast Healthcare Interoperability Resources, more commonly known as FHIR.

What is FHIR?

Healthcare organisations leverage FHIR for storing and exchanging electronic medical data. Health Level Seven (HL7) International, an organisation that develops standards to support the integration and sharing of healthcare information, initially published a draft FHIR specification in 2012. The most recent draft FHIR specification is version 4, published in 2019.

While previous interoperability standards exist, FHIR is able to build on available and mature web technologies, such as REST for service APIs and JSON for payload delivery. This gives FHIR a distinct advantage in terms of integration with other systems. FHIR also incorporates, by design, the concept of workflows, defining many different Resource types that can combine to support the most common use cases for clinical observations and services. This offers on-demand access to data, something that is not technically possible with an EMR alone. And, again by design, data shared using FHIR may partially expose some information without compromising security. Messages can be understood by analytics platforms for real-time data gathering, for example, machine learning, while protecting patient privacy.

FHIR provides access to resources and services in the same way a URL, or ‘link’, represents an address or service online that anyone may use. Because of this, FHIR has the potential to make healthcare user workflows closer to other cloud-based experiences. The way FHIR structures data greatly simplifies sharing of the data between existing systems in addition to new systems currently being developed, and hence between teams and organisations.

Healthcare data is represented by ‘Resources’ in FHIR. Each Resource includes a URL, to identify the Resource, metadata, that aids in searches and provides context, a human-readable section, and a set of data elements that is different for each type of Resource. Sophisticated applications can be composed offering flexible views of information from multiple sources including clinical observations, real-time data and environmental information.

Why the healthcare industry needs FHIR for interoperability 

Currently in Australia, and around the world, healthcare systems are made up of a mix of technologies. Patient management systems, payment systems, pathology providers, booking engines, secure messaging providers, public health systems such as Medicare, prescription systems and drug interaction databases. These systems all rely on isolated technology platforms that are outdated and were never designed to work with other systems.

To have better, affordable, healthcare overall, a more efficient means of collaboration between all of the separate systems needs to be available. This is the crux of why healthcare interoperability is so important and why FHIR is needed.  For example, the pathology lab may share results with the specialist doctor via a workflow that looks up the current patient medications, consults the drug interaction database, and finally the pharmacy via the prescription system, all in real-time. FHIR is designed with this kind of workflow in mind, to exchange the relevant information needed, securely, and quickly.

Adoption of the FHIR specification, together with the rich set of tools and services slowly being developed by vendors, can help unify healthcare and improve interoperability. They will streamline interactions with patients, providers, and administrative staff. As with the underlying FHIR principles, these modern tools and services are being developed with future requirements and use cases in mind. Developers can build standardised applications to allow access to data across different FHIR implementations. The ease of use and flexibility has gained FHIR the support of international healthcare industries and major technology providers like Google, IBM, Amazon, Microsoft and Apple.

In Australia, ‘If the government goes by examples in the US and the UK, it is going to give vendors and providers only five years to get their act together in respect of certain based standards for interoperability’ (from Wild Health, 9 Aug 21). FHIR is that standard.

Where and how should FHIR be used?

FHIR is mainly used when developing applications using a repository of health information, such as an EMR. For example, if you are developing an app for Apple’s iOS platform, FHIR is used to pass health records to and from HealthKit. Similarly large EMR systems used commonly in hospitals, such as EPIC and Cerner, publish FHIR APIs for developers. FHIR is also used when there is no single source of information. The bringing together of scattered personal health records is a particularly useful FHIR workflow. FHIR applications are often implemented with the help of additional frameworks, in particular the SMART on FHIR framework, which provides application-centric capabilities such as authentication and higher levels of API abstraction to allow for easier development.

Challenges in FHIR adoption 

One of the most prevalent challenges of FHIR is slow adoption. There are several reasons why providers might be reluctant to switch to FHIR. The first is that organisations will expect a certain level of completeness before fully transitioning. Most companies, governments, and healthcare providers have worked with the same standards for over thirty years and invested millions in maturing their tools. FHIR standards are new, by comparison, so there are not many use cases yet, relatively speaking, making potential users more cautious. When dealing with health information, erring on the side of caution is often the case, which means uptake of new standards and protocols takes time.

Some EMR and IT vendors are not ready to fully implement FHIR APIs, which can create inconsistencies that undermine the adoption of the standards. In addition, the right tools will require some time to be planned and deployed. You should complete this at a pace that feels right for your organisation. FHIR adoption also might require changes in IT infrastructure and ongoing investment in maintenance, training, and support. 

Lastly, and encompassing all the previous points, there is a cost issue. Even though interoperability is highly beneficial in the longer term, the transition period can delay the more visible results.

Healthcare interoperability with Fluffy Spider

We create fully integrated, software systems for interoperable digital healthcare that manages the electronic health data journey from devices to the cloud and medical record systems.

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