It's undeniable that electronic health records (EHR) brought a new level of sophistication and scalability to the healthcare industry. They allow patients and physicians to have up-to-date and accurate records, create a more coordinated care system and enable providers to share information securely. But, as vendors raced to the market to develop the best EHR system, interoperability was looked over and not considered a selling feature. 

Fast forward to 2021, and interoperability is now mandated through a variety of regulations. The hundreds of licensed EHR systems available paired with the consistent innovation and lack of interoperability oversight left the healthcare industry scattered and looking for a way to unify the disparate data across the country. To create an actual interoperable system, the healthcare industry needed to identify a framework that allowed them to manage inconsistent information, validate electronic requests, and overcome organizational resistance, all while staying within a reasonable budget. 

Enter the Fast Healthcare Interoperability Resources (FHIR). FHIR was explicitly created to unify disparate records and allow the healthcare community to seamlessly share data regardless of the ways local EHRs represent or store their information. It is a relatively easy to learn framework, has a very supportive and helpful community behind it, and can facilitate interoperability with legacy EHR systems, regardless of if they support the standard.

What is Fast Healthcare Interoperability Resources (FHIR)

FHIR, pronounced Fire, is a set of data sharing standards developed by Health Level Seven International (HL7) that enables the electronic exchange of clinical information. FHIR combines the most practical features from previous standards with a fresh internet-based approach to enhance interoperability and ease data exchanges across the dynamic healthcare ecosystem. It is an implementation-focused set of standards based on RESTful principles that allow new applications and legacy systems to more easily share information than in the past. Using proven standards and technologies permitted  the development community to adopt FHIR quickly and create new cutting-edge technologies that support healthcare needs.

A Brief History of FHIR

FHIR began being developed in 2012 by Graham Grieve and a small team working alongside HL7. Graham believed that FHIR's predecessor, HL7v3, had failed as an interoperability solution due to its complexity and low use rates. His goal was to create new standards for exchanging data using well-known and highly adopted technologies like HTML, JSON, and XML. 

The FHIR development team began involving standards organizations and governments in their development process to ensure the standard continued to improve and was eventually adopted by leading EHR vendors, including Cerner, EPIC, and AllScripts. Over the next couple of years, it continued to address interoperability issues by empowering the creation of cutting-edge applications. One of the groups that saw potential in FHIR was Substitutable Medical Applications, Reusable Technologies (SMART), founded in 2010 out of the Boston Children's Hospital Computational Health Informatics Program. SMART started in 2010 with a $15M grant from the ONC with a goal of enabling developers to create healthcare applications that would work at any healthcare organization, regardless of their EHR.

In 2013 SMART recognized the traction that FHIR was gaining and decided to join forces instead of pursuing their framework. They quickly began creating tools and guidelines for developers building FHIR-based applications and supplied infrastructure and security measures that FHIR had not had before. 

Today SMART on FHIR provides two primary services, a framework for building FHIR-based applications and a platform to publish and access FHIR apps. SMART also developed an authentication mechanism using OAuth to approve third-party applications' access to EHR data and implemented OpenID Connect to ensure a safe sign-in to those apps. 

FHIR was available for free and went through multiple iterations before being published as a Draft Standard for Trial Use in 2014 and continued to go through iterative improvements as industry stakeholders began to implement it as their interoperability standard.

Who Uses FHIR 

Today FHIR is one of the most in-demand interoperability standards available and is used in thousands of applications that support patients and the healthcare industry. It has been adopted by many health systems, some of the most prominent EHR vendors, and companies in the private sector who are disrupting the industry with new and innovative technologies. A few of the most prominent organizations utilizing FHIR include Boston Children's Hospital, Duke Medicine, Healthcare Corporation of America, Epic, Cerner, Allscripts, Apple, and our team at Health Gorilla. 

The Benefits of FHIR for Providers, Patients, and Developers

Benefits for healthcare providers

FHIR enables providers to quickly access important clinical information, including electronic health records, administrative data, claims data, and more, allowing them to make informed and timely treatment decisions. It also facilitates better collaboration with payers, which is becoming more critical as the healthcare industry transitions to a value-based reimbursement model. Increasing cooperation between providers, payers, and individuals has multiple benefits, including better care coordination, prevention, and condition management, while simultaneously capping costs.

Benefits for Software Developers

FHIR was created to ease the implementation process and allow developers to focus on their product's actual value. It is free to use, utilizes common web standards, like XML and JSON, and comes with off-the-shelf interoperability. Developers also have access to HL7's detailed documentation, free tools from the FHIR community, and implementation libraries, allowing them to kick-start and scale their development. 

Benefits for Patients

FHIR can truly empower patients. As stated above, FHIR, and more specifically SMART on FHIR, has made it easier for developers to build health applications that integrate with EHR systems, which has allowed providers and patients to quickly find an app that offers their optimal user experience. Allowing patients to use their desired applications to access their clinical information will enable them to take control of their health and make better decisions about their medical care. It will also drive patient engagement and keep them updated on lab results, allergies, medications, procedures, and more.

How FHIR Enhances TEFCA's "Network of Networks" Structure

When the Obama administration signed the 21st Century Cures Act in 2016, one of its primary goals was to accelerate medical product development and bring innovations to patients. The Cures Act also advocates for the delivery of more significant interoperability standards to prevent electronic health information (EHI) blocking between health systems and promotes the adoption of electronic health records. 

After signing the Cures Act, the Office of the National Coordinator for Health Information Technology (ONC) was called on to "develop or support the trusted exchange framework, including a common agreement among health information networks nationally." The ONC, alongside the Sequoia Project, the Recognized Coordinating Entity (RCE), created the Trusted Exchange Framework and Common Agreement (TEFCA), which, when released in the first quarter of 2022, will establish a floor of universal interoperability across the country. It will also develop the infrastructure and governing approach for the Trusted Exchange Network and include the qualifications that organizations must meet to become Qualified Health Information Networks (QHINs), the certified entities responsible for facilitating the national exchange of health information. QHINs will act as connectivity brokers to ensure interoperability between the networks they represent and responsible for the onboarding and management of their Participants and Subparticipants. 

After a detailed review of the second draft of the QHIN Technical Framework, our team provided feedback focused on the benefits of FHIR and strongly advocated for its inclusion as an alternative standard for message delivery.

Our team agrees that a reliable message delivery system is critical to the success of TEFCA but believes that excluding FHIR from the framework will disrupt the innovation that has taken place. Incorporating FHIR into the QHIN Technical Framework will not only reduce the development learning curve, but it will also make real-time interoperability easier and enable innovative applications to be created. Its principles of reuse, performance, usability, fidelity and implementability align well with the goals of the ONC and TEFCA and have the ability to truly impact the healthcare community when the RCE begins designating QHINs next year.

Health Gorilla was an early adopter of FHIR and now offers a suite of industry-leading FHIR-based clinical APIs compliant with FHIR R4 profiles. Our APIs power fundamental healthcare workflows and data exchange scenarios and are viewed as an easy "on-ramp" for organizations looking to exchange data nationally. In May of 2020, our services were recognized in the Duke University Interoperability Report as the only clinical exchange portal that met functional and security requirements for public health departments. The report stated that Health Gorilla, who is a Member of CommonWell and an Implementer on Carequality, "provides query access to all acute care sites on both networks, and maintains its own set of services (MPI and RLS) and capabilities (event notifications) that could increase utility for public health. We have seen firsthand how impactful the framework can be for the healthcare industry and will continue to offer FHIR exchanges whether it's part of the final TEFCA regulations or not.

What's Next for Health Gorilla?

Health Gorilla will be applying to become one of the first designated Qualified Health Information Networks under TEFCA once the final Trusted Exchange Framework is released.

We have been working under the known regulations set forth by TEFCA, are committed to the legal, functional, and technical requirements, and are prepared to satisfy all six exchange purposes.

We will continue to be active stakeholders and thought leaders, supplying public input on the TEFCA model as the documentation and requirements continue to evolve and encourage the ONC, RCE, and healthcare community to look at our uses of FHIR as examples of how impactful it can be when solving healthcare interoperability. 
We look forward to expanding our services and facilitating access to health data across the country with our flexible platform, unique national master patient index, and FHIR-based clinical data APIs.