Episode 19: FHIR is Transforming Interoperability in Healthcare


On this episode of the Dish on Health IT podcast, guest Charles (Chuck) Jaffe, CEO of Health Level Seven (HL7) speaks with Ken Kleinberg and Jocelyn Keegan about the history of FHIR, FHIR adoption today and tomorrow, and why non-technical people should get more involved in the standards development process.

Chuck provided a brief overview of his background including his education as a medical doctor and then additional education in computer science. Chuck transitioned to working with the National Institutes of Health (NIH) focused on immunology and oncology. He then worked for AstraZeneca as its first global head of medical informatics before moving on to SAIC as the VP of a large biomedical community. Chuck’s journey ultimately led him to HL7.

Chuck shared that over a decade ago was when he was first introduced to what would eventually become Fast Healthcare Interoperable Resources (FHIR). Grahame Grieve introduced the concept of FHIR after realizing the positive impact Application Programming Interfaces (APIs) could have in healthcare. FHIR has since been on a trajectory that has accelerated beyond Chuck’s expectations.

Ken pointed out that some of the traction gained by FHIR is in response to the policy. He then went on to ask Chuck the impact FHIR will have on point-to-point interfaces. Chuck responded that FHIR was first envisioned as a way to share data between an individual patient record and an individual provider record to circumvent some of the more cumbersome processes already in place. Original HL7 standards didn’t envision the possibilities of the future environment that went beyond push only data exchange. So, what began as a point-to-point solution has grown enormously as FHIR has embraced other technologies.

Jocelyn quipped that as FHIR began to emerge, it was pleasantly surprising how easy it was for developers to pick it up and use it. Another key to FHIR’s success has been the focus on identifying the problems that need to be solved and clearly defining the use cases. It’s also important to realize that we’re using the existing the infrastructure and transitioning to a purist FHIR ideology. FHIR will be used in concert with other standards to solve industry problems.

Chuck agreed and gave an example of feedback he heard at a conference early on where a stakeholder with a complex infrastructure shared that they saw FHIR as a way to augment their existing infrastructure. Their first FHIR implementation took two months and they thought that was fast, but the second implementation only took two weeks!

Jocelyn shared her experience of getting her first smart phone. Her imagination of how she could potentially use the various apps available was limited “maybe I’ll be able to check my email when I’m away from my desk.” Cutting to now, she drives her life from her phone. She compared FHIR adoption to her smart phone experience by saying that early FHIR adopters are still uncovering secondary, tertiary and fourth and fifth use of data that previously had been siloed and begin to do things they never would have been able to do previously.

Ken moved the conversation along by asking about the push for FHIR Implementation, after all, concepts aren’t valuable unless they are implemented. Chuck responded by saying that the  standards world was slow to accept and adopt FHIR at first. Those communities have come to accept that the concept of APIs makes interoperability incrementally more seamless. It wasn’t so much an act of persuasion but simply the growing body of evidence demonstrating what FHIR APIs could do. Chuck shared that back in the day that at conferences, he used to ask the audience “Are you familiar with HL7? Have you heard of FHIR?” and now he asks, “Who is currently implementing FHIR?”. Chuck shared that he is extremely excited about what the future will bring.

Ken inquired about the challenges and keys to manage the collaboration required across so many stakeholders. Chuck responded that the elephant in the room is change management. There are so many sunk costs in legacy systems and that must be recognized. The industry doesn’t really continue to recognize some of these legacy systems but there is an opportunity to look ahead and view the legacy systems as a foundation to build upon. There will be greater opportunities in the future.

Jocelyn agreed with Chuck’s assessment and added that FHIR is an enabler. There was unmet demand to solve seemingly simple problems of data exchange with partners. Rather than share data every 4 hours or daily or every week, partners can now create access points that allow real-time exchanges. This is a good example of how the industry is leading and exploring the possibilities and policy is following rather than policy forcing change.

Chuck added that security and safety will eventually be embedded in the technology. He provided an analogy about how there is a transition from using metal house keys to using apps or keypads to gain entries into our home. For now, sometimes it may be more convenient to use the physical key instead of an alternative method but as technology continues to advance, one day people will wonder how we ever used physical keys.

Jocelyn pointed out that it's common to hold recent technologies to a higher standard around security and privacy and put those concerns up as barriers to adoption when there are huge gaps in security and privacy in our current system as we’re using PDF files and faxes that can’t be traced.

Chuck shared an example of this. He had a patient that needed a lab test outside of the university system so he asked the national lab company if he could enter it through the portal, but he wasn’t registered, and he was advised that he had to write the lab request on a prescription pad. The lab company then asked where to fax the results. They said they must fax the results due to security concerns. Chuck informed them that he didn’t have a fax machine and asked if they could email it. They proceeded to try to fax the results to his phone number for a week before finally emailing the results. It’s extremely hard to get people to change when they have processes in place and sunk costs. That’s the challenge FHIR faces.

Ken asked Chuck to speak to some of the collaboration happening internationally and how we can learn from it. Chuck assured him that there are a lot of examples that we can learn from whether from their regulatory bodies or the solutions that have emerged. Canada, Australia, and Argentina have done amazing things through their national health systems. A change that’s very heartening is that while FHIR has always been free of charge to use there is now documentation in various languages and based on those countries customs to make it easier to adopt internationally.

Jocelyn pointed out that while POCP tends to do US-based work with some work with our neighbor to the north (Canada) that there is a community aspect to FHIR that allows us and all stakeholders to convenes and learn from each other whether through Connectathons or creating their own community to focus on specific areas.

In closing, Ken asked Chuck what he wants listeners to do with the information from this episode. Chuck responded that he’s been driving a car for many years without knowing specifically how the car works. He doesn’t need to know in order to have confidence that car will crank with the turn or a key or press of a button or to have opinions about what could be done to make the car better for him. He encourages people who are not technical to come and participate in the standards development process. Not as a code writer or developer but being able to come and articulate their needs and the problems they need to solve so the solutions will be based on real-world needs. Jocelyn echoed Chuck’s point adding that it’s really connecting the technology experts with the people using the data and doing the work day to day that have intimate knowledge with workflows and the hiccups to them.







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