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HL7 releases new FHIR standard, but don't expect true interoperability

Achieving interoperability is a major undertaking, something the FHIR standard alone won't be able to accomplish, according to one HL7 organizational member.

In early January, Health Level Seven International, a nonprofit standards organization, announced the fourth release of the Fast Healthcare Interoperability Resources standard.

Charles Jaffe, CEO at HL7, described the new version of the FHIR standard as having achieved a "critical milestone." But an executive at Redox, a healthcare data exchange company using the FHIR standard and an organizational member of HL7, said the healthcare community shouldn't see this as an interoperability fix.

Niko Skievaski, co-founder and president of Redox, said the FHIR standard is a tool and not a solution. He believes the standard has been overhyped and that the problem of interoperability is too big for the standard to solve.

A look at FHIR R4

Jaffe said the biggest news for FHIR R4 is that some characteristics have reached "normative" status, a designation by the American National Standards Institute to indicate a level of stability and maturity. The newly normative characteristics, described as FHIR's "base platform" in a press release, are also backward compatible, which means they will work in future versions of the standard.

FHIR R4 is another attempt at getting the healthcare community closer to true interoperability, which Jaffe said not only means receiving data but understanding it and being able to reuse it.

FHIR is not the solution to interoperability. It is a tool and that tool needs to get better and refined.
Niko Skievaskipresident, Redox

"HL7 FHIR R4 is a beginning," he said in a statement when news of FHIR R4 was announced. "It is the legacy of eight years of innovation and collaboration among a community of thousands around the world. It is a commitment from HL7 to create a platform from which interoperability can someday emerge. It is a promise to provide reusable data across the continuum of biomedical research, patient care, and population health."

There are still "enormous hurdles" to overcome – technically, as well as culturally, Jaffe said. But he pointed to FHIR standard's API, a software architecture that enables computers to talk to each other, and its ease of use for programmers as two notable features that push the interoperable envelope.

"There are two things FHIR achieves," he said. "One is there's a set of vocabulary that we all agreed what it meant. And two, there are capabilities for exchanging information that have never been achieved prior to this in healthcare."

Issues facing the FHIR standard

But Skievaski doesn't believe the FHIR standard alone can achieve the goal of interoperability. "I feel like we're getting to a point where we're kind of riding the downward slope of the hype curve," he said.

Redox is an active player in healthcare interoperability. The Redox platform offers a network of enterprise healthcare applications, including its own API, for software developers to connect to and use in any health system or EHR. The company also supports and uses the FHIR standard, and released its version last year, which Skievaski said points to one of the biggest challenges.

Anyone who implements the FHIR standard can customize it and create a unique version, Skievaski said. The ability to customize the standard benefits EHR vendors and large, established healthcare systems because they can bend it to meet the provider's needs. But doing so hampers interoperability because it can result in an endless amount of versions of the standard instead of one, cohesive standard, Skievaski said.

"When it came down to actually implementing it, we saw inconsistency," Skievaski said. "We see inconsistency because inconsistency is built into the specification itself."

Skievaski said there are other hurdles to interoperability that are beyond the FHIR standard's control, such as lack of incentives for healthcare players to open up their data. Health systems compete with each other and getting them to share data is like asking Target and Walmart to share their customer database, Skievaski said. EHR vendors, often the source of healthcare data, also lack incentives to be interoperable, he said.

"The industry is not going to implement something if it doesn't have an economic incentive to implement," Skievaski said. "And that's what's difficult about interoperability."

Skievaski said although he doesn't think the FHIR standard will solve the issue of interoperability, making improvements and releasing new versions is an important undertaking to help the standard "find its footing and find its place."

"FHIR is not the solution to interoperability. It is a tool and that tool needs to get better and refined, so versioning is really important," Skievaski said. "It needs to exist and we need to be moving the standard forward, but it is not the solution."

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