Episode Topic: HL7 FAST - Building a National FHIR Infrastructure is Fundamental to Scalability


Ken Kleinberg, Innovation Lead, greeted guests and listeners explaining that The Dish on Health IT is a forum for Health IT innovators and catalysts to break down and discuss some of Health Its biggest news and most exciting milestones and that it is produced by Point-of-Care Partners (POCP) Health IT Consultants who work with stakeholders across the healthcare ecosystem. Viewed as an independent trusted party. 

Ken was joined on this podcast by co-host, Jocelyn Keegan, Payer Practice Lead. They welcomed this episode’s guests who serve as co-chairs of the HL7 FHIR at Scale Task Force or FAST, Deepak Sadagopan, Chief Operating Officer of Population Health with Providence, and Duncan Weatherston, CEO of Smile Digital Health joined the podcast to dig into what FAST is up to now that it's transitioned from an ONC initiative into an HL7 FHIR accelerator the importance of building a strong framework for a national FHIR infrastructure, why FHIR scalability is crucial and how coordination and collaboration across the FHIR Community are integral.

Jocelyn Keegan briefly introduced herself explaining that FAST sprung out of the leaders within Da Vinci recognizing there were critical components needed for FHIR implementation to happen smoothly and at scale so all the great implementation guides coming out of Da Vinci and the other Accelerators can more easily be picked up and used. The work of FAST is truly foundational. 

Deepak introduced himself expressing how much of a pleasure it’s been to work alongside Duncan and that he’s looking forward to all the work they have in front of them. He explained that he is the Chief Operating Officer for Population Health with Providence Health System and that he has been actively engaged in the standard space and particularly as it relates to the adoption of FHIR for the past few years. He explained that advocating for standards in the value-based care space and following the path CMS has laid out is the North Star of much of his work. 

Deepak continued to say that in order to benefit the entire population a foundational infrastructure that supports scalable adoption of modern standards is needed. This will help reduce administrative burden and improve the patient experience. FAST’s work really resonated with me because I see the work as helping solve not only industry challenges but specific challenges my own organization faces. 

Duncan then introduced himself saying that he shares Deepak’s enthusiasm for the team that has been put together to support the FHIR and Scale Task Force. Adding that all the members are well informed and have a deep belief in the value of the FHIR proposition and are really interested in ensuring that all of the community have the tools they need to be able to participate effectively which is essentially the heart of what FAST is trying to do. 

Duncan shared that he has a background as an architect in healthcare since the late 90s. He went on to say that he has played roles across different aspects of healthcare like population health and primary care systems. He went on to explain that his interest in FAST was due to the synergies in mission between FAST and Smile Digital Health, the company he founded.

He went on to say that he believes the API-driven approach to Health Care is the necessary bedrock for real transformation in care delivery. He compared the transformation in healthcare to the transformations in finance or music industries adding that healthcare is much more complex which is why having stakeholders bringing their various perspectives to the table is critical to solving healthcare’s biggest challenges. He added that FAST has a long path ahead. 

Ken asked Duncan to share a little bit more about FAST’s history and the current status of its work. 

Duncan explained that the FHIR is Scale Task Force started as an ONC-convened initiative with the goal to solve common implementation challenges by building on the work the industry had already started and identifying other gaps that needed to be addressed. FAST then transitioned into an HL7 FHIR Accelerator to continue its work as an independent body. Members include stakeholders like EHRs, payers, health systems, really the whole gamut. The focus is to establish consistency in the adoption model, adding that ideally all of us should be singing from the same songbook when it comes to how we interoperate in this sort of burgeoning API landscape. 

Ken expressed his appreciation of the concept of solving common challenges and creating a common adoption model for the FHIR Community. He then transitioned to asking Deepak to share examples of real-world challenges provider organizations like his face that the work of FAST would help to solve. 

Deepak responded by sharing a scenario related to the wide geographic area across the west coast that Providence serves. Quality measurement for any organization like Providence is incredibly important because if it isn’t measured, it can’t be addressed. This quality data must be collected across all affiliates and partners to support Accountable Care Organization (ACO) and other types of arrangements where Providence and its affiliates and partners are held accountable for quality and total cost of care for a defined set of populations. 

On its face, this may seem simple, however, when one considers that a region may have as many as 45 different affiliates using 23 different electronic health record systems, one sees that the data is still very siloed. He continued to explain that when attempting to measure the quality of care for 300,000 beneficiaries covered under different ACO arrangements and 10 different payers, creating one platform or dashboard for all quality data is incredibly challenging. 

He continued by asking listeners to imagine a state where it’s possible to have one central dashboard that can be queried to bring up patient data indicating the associated payer organization, which provider organization is able to use APIs to deliver data related to this patient or the set of patients both in terms of claims and clinical data associated with all the organizations that know about that patient and have interacted with that patient before. This would dramatically simplify the effort required for system-wide quality measurement. 

Ken empathized with the challenges stakeholders face. He went on to say that FAST is focused on infrastructure and scalability that would address some of these challenges. To gain further clarity on FAST’s work, Ken asked for either of the guests would like to expound on how FAST fits in with the other HL7 accelerators. 

Duncan explained that he sees FAST as an Accelerator for Accelerators. FAST is trying to fill the gaps and overcome barriers to scalable FHIR Solutions. In addition to the implementation guide development, FAST is coordinating and collaborating with other Accelerators and organizations to align the FHIR community on policy and approaches to issues and harmonize existing efforts. The FAST implementation guides address scalability challenges related to areas like identity, security, and intermediary access for a consistent way to proxy content backward and forwards and also a provider directory. The current set of FAST IGs is pretty fundamental to the infrastructure deployment we have in mind but more than that, FAST is exploring opportunities to work on other collaborative strategies to support the creation of capabilities to operate across different governance frameworks or accountability agreements. 

Ken asked Jocelyn to weigh in wearing her Da Vinci Program Manager hat. 

Jocelyn referenced back to the scenario Deepak shared saying that as stakeholders need to exchange data across thousands of providers, and hundreds of payers to support an endless number of different agreements, someone needs to look at the macro picture to figure out what foundation guides or work are needed. She went on to say that Providence as an organization, while complex, is innovative and mature and their early work can serve almost like an advanced team, feeling out the challenges others will face. She continued to explain that right now, finding out which organizations have a FHIR server live, is a very manual process. In a future scenario, stakeholders should be able to publish their endpoints to a directory and allow it to be discoverable without having to manually do anything. Jocelyn went on to say that she believes FHIR adoption is much higher than currently reported partly because it’s impossible to get a realistic view of live servers without having an endpoint directory. The industry agrees that using these modern standards is important but if these foundational pieces aren’t addressed, we won’t be able to achieve the level of automation we’re looking for. 

Deepak responded to what Jocelyn said by agreeing and offering that some tracking of partner organizations can share data is being done using excel spreadsheets. He added that problem number one is consistency in the adoption of standards. In an ideal world, every endpoint should communicate information such as which patients are covered under their particular ACO arrangement in the same way. Next, stakeholders don’t want to have to develop 10 different connections and have 10 different ways to indicate payer and patient data or require manually checking 10 different organizations. A directory-type structure would help. There needs to be consistency in approach and consistency in the adoption of the standards and the scalability across these different endpoints. He explained that so far, we've been successful in solving it in small microcosms but it's nowhere near the level of scalability required.

Ken, in follow-up, probed about what is meant by scalability. 

Duncan responded by saying that some may look at scalability as being able to handle a high volume of transactions or lots of lots of data flowing backward and forwards and of course once we're at scale we have to support that. He referred back to what Deepak pointed out that it's really important that organizations be able to reach out to hundreds or thousands of others and that everyone is doing it in the same way. The way FAST sees scalability is creating a consistent fashion in which every endpoint can have a reliable and predictable mechanism by which they can discover, relate, log in, transact, and retrieve information the same way every time. He went on to say that the problem stakeholders face today is that we live in this heterogeneous environment if an organization needs to work with providers, they have to work with each provider discreetly and then providers working with payers have to coordinate with each payer discreetly. He continued that it doesn’t stop there, the problems of a heterogeneous environment extends to researchers trying to gather information, or really any stakeholder within the healthcare ecosystem will face the same set of issues. This is why it’s important to deploy a scalable methodology for information exchange. 

Ken responded by saying that he understands the leveling aspect of being able to get everybody in a consistent methodology at scale is incredibly important. He went on to say that it made him think of the different types of railroad tracks across different parts of the world or mobile phone networks, ATM networks or electrical standards. He shared that his daughter's traveling through Europe now and she has a whole bag full of different plugs for the different countries she’s traveling to that she's going to face. He asked if one of those comparisons was apt for what is going on in healthcare or if there was another preferred analogy. 

Duncan responded by saying that he thinks those are good comparisons to a point but went on to say that the key thing to remember is that those power plugs work regardless of whether you're plugging in your laptop, a stove or your electric car. Each may have different connectors or run on different volts but the fundamental grid that supplies that power is consistent. The idea that we all have the same experiences is very important. One of the advantages that we see with the plug system is at least within broad regions, the plugs remain the same whether in Seattle or Miami the plug I the same. If traveling to London one might need an adapter, but no one will need to break out a toolkit to rewire a device and through trial and error and a little bit of smoke get everything working. He added that if everyone had to bring an electrician with them on vacation, electricians would be in way more demand than we could ever supply. That's where we find ourselves today 

Ken followed up by asking how FAST goes about creating these common solutions and common implementation models and then pulling them through to adoption. 

Duncan responded that currently FAST has four implementation guides that have gone through the rigorous and transparent standards development process. In addition to that kind of work, FAST working to bring the community to the table to talk about the problems that they're discovering with scalability and then expose those as potential collaborative pathways going forward. FAST does that through communication and staying in contact with the other Accelerators and other implementers and keeping our ears to the ground for opportunities to collaborate. 

Deepak added that he looks at FAST as essentially a shared service for all the other Accelerators like if you think of all the other Accelerators or as individual business units and FAST is a common service that supports each of these other accelerators in enablement and scaling the standards they are developing, that is what FAST is focused on. 

Jocelyn spoke up to agree and add that the cross-pollination FAST has brought into the HL7 community has been really powerful and has helped tighten those connections. She added that having worked on a number of the Accelerators over the last few years one can’t discount the value of convening conversation discussing and brainstorming with peers on how to solve complex problems.

Ken asked for thoughts on the Trusted Exchange Framework and Common Agreement or TEFCA. He mentioned that TEFCA recently announced a first wave of half a dozen organizations approved as the so-called qualified health information networks or QHINs. He added that while TEFCA isn't a FHIR-specific framework although there is a recently introduced FHIR road map with payload support as well as facilitated and brokered FHIR Exchange in the future Ken asked whether TEFCA is on the right track. 

Duncan responded by saying that the intent of TEFCA is admirable and I believe that their goals are very well aligned with what FAST is trying to accomplish in the FHIR community. He added that the critical piece is to ensure there is a consistent strategy and a consistent set of standards for all of the members and participants in the community to be able to share information whether exchanging as part of TEFCA or outside of TEFCA. 

He continued by adding that the most important point is to avoid divergent standards. Duncan shared, that in his view, the implementation of TEFCA must align with the standards implementation community or else stakeholder will have to continue operating in a heterogeneous environment and trying to figure out what rules apply within TEFCA that might be different from everywhere else. 

Deepak concurred with Duncan’s point that avoiding divergence is the most important thing. He added that TEFCA is engaging with the FHIR community and soliciting feedback and he hopes to see more of that to lead to better alignment. He added that if we don’t gain alignment now, it will be much more difficult to address the new issues introduced into the ecosystem down the road.

The group discussed the relationship between standards and policy and the interconnectedness between them. All agreed that policy continues to be a powerful lever to move the industry towards interoperability even if things don’t move as quickly as everyone would like. 

Closing out the episode, Ken asked the guests to share any final messages or calls to action for the industry. 

Duncan responded by saying that the industry is in the process of transformation from a pre-internet to a post-internet model. He continued by saying that every organization has an opportunity to evaluate what can be learned and applied from other industries that have experienced massive transformations. The industry also needs to recognize that it is an information industry. He added that it sometimes feels like healthcare is stuck in a debate on whether it is a bricks-and-mortar industry or information. He added that in his view it is very clearly an information industry and the adoption of standards like FHIR allows data exchange directly point to point in a consistent fashion. He continued by recommending organizations evaluate their role in the community evaluate their use of information and figure out how they can become part of this transformational solution so that patients get the best care at the most affordable rate.

Deepak added his voice saying that he has been in the interoperability space for over 20 years now and that the industry is in a really exciting place. The whole industry is more active and engaged in this space. So many are taking an interest in liberating data from electronic health records and really figuring out how to democratize the use of healthcare data to drive better care and outcomes for the populations we serve and that is incredibly exciting to see. He added that of course the industry can sometimes get caught up in short-term challenges but that leads to healthy debate that will allow us to end up in a spot that leads to better outcomes for the Patients. 

Jocelyn implored stakeholders to pay attention to the work being done and to come to the table and share the business problem they're trying to solve and what data they're trying to free or if they’re already down the implementation path to participate in testing. She concluded by recognizing that FAST is looking to move the industry into the future with a practical approach. 

Ken closed out the episode by thanking the guests and his co-host and reminding listeners they can find the podcast on Apple podcast, Spotify or wherever you get your podcasts and to check out the POCP YouTube channel for videos of episodes. 

FAST will be speaking on March 22, 2023 on an HL7 webinar. Register here. FAST will share a kiosk at ViVE in the InteropNow Pavilion and have a kiosk at HIMSS23 in the Interoperability Showcase. Reach out to FAST to learn more by emailing fast@hl7.org

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