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Current environment, issues and challenges of the Electronic healthcare information exchange

Discuss about the Fast Healthcare Interoperability Resources (FHIR).

Electronic health records (EHRs) help doctors, pharmacists, nurses and healthcare professionals along with patients to share vital medical information in an appropriate and secure manner (Koopman et al., 2015). Various standards are designed acting as medium for exchange of healthcare information electronically. Among these, Fast Healthcare Interoperability Resources Specification (FHIR) that aims at simplifying the implementation of data exchange standard without compromising on the information integrity. FHIR leverages existing theoretical and logical models in providing easy implementation, consistent and rigorous mechanism for the data exchange in healthcare applications (Yan, Xiaoa & Tian, 2017). Therefore, the following discussion deals with the purpose, application and further aspects of FHIR along with current healthcare issues, challenges and how it has contributed to the existing knowledge of exchange of healthcare information.

In the light of the healthcare ecosystem anticipated from the current system changes, EHRs has widespread use in the health information exchange. There are potential benefits as well as drawbacks of these electronic healthcare information exchanges. Electronic healthcare information exchange have the potential in transforming the healthcare system from paper-based to more clinical and information-based assisting healthcare professionals in delivering highest quality of care and ensure patient safety. In the current scenario, many federal policies, actions are supporting healthcare system to adopt health information exchange (HIE) for improved and secured exchange of personal health information (Bahga & Madisetti, 2013). To facilitate this, concerted efforts are being made to incorporate EHRs from the last two decades in the healthcare system. Various challenges are being faced by the healthcare system like mobile population, prevalence of chronic diseases, natural disasters, growing pharmaceutical use and serious pandemics. HIE is a solution to these problems that help to share patient-level information electronically between healthcare professionals and different organizations (Hussain & Qamar, 2016).

The underlying belief in HIEs is to help patients, as relevant information is being available to the healthcare professionals in treating and maintaining their health. This shows that the vision is challenging as the current healthcare system is provided with organizational diversity and disparate healthcare information systems. The system is facing challenges regarding the shortage and investment in resources required to develop an environment that allows electronic healthcare information exchange following the patient. There is also issues regarding the investment of time, resources that are required to achieve HIE goals (Adler-Milstein, Gilbert & Jha, 2015).

FHIR and its purpose

The effectiveness of HIE is supported where it reduced the duplicative radiology and laboratory test ordering, hospital admissions, lowering of ED costs with improvement in public health reporting, disability claims and increased ambulatory quality of care. However, it also reported that HIE implementation and functioning is limited with low impact and outcomes. On a contrary, the adoption of HIE is increasing in the hospitals and ambulatory care, however, HIE use rates are low within organizations. There is lack of comprehensive effort required to track the rate changes within the healthcare organizations (Rahurkar, Vest & Menachemi, 2015).

Several barriers have been studied for HIE implementation including inefficient workflow, lack of critical mass in electronic health exchange data, poor updated features and designed interface. This shows that there is barrier in the usability and use of HIE in the current healthcare system. There are also limitations like incomplete description of architecture and functionality of HIE that makes its implementation difficult. In regards to the sustainability, various factors acted as barriers to HIE implementation in the organizations like internal and external environment like leadership and concerns regarding competition (Rudin et al., 2014). External policy consisting of grants and laws acted as barriers where the changes or timelines in requirements pose burden on the healthcare organizations (Ben-Assuli, 2015). Financial viability is the most frequently cited barrier including the disincentives and mismatch between who would invest and who would benefit from HIE (Vest & Gamm, 2010).

Another key is the lack of critical mass where the data were incomplete due to lack in patient information or matching of patients across the healthcare systems. Interface and system features also acted as hindrance in HIE adoption like difference in user opinions on whether they wanted less or more information or scrolling or clicking multiple pages. Moreover, HIE users also reported slowing down of the systems when data needed to be expanded during inclusion of more information or patients. Completeness of HIE also acts as a barrier as its use is increasing and healthcare professionals assume that information is being exchanged completely and everyone has the information exchanged. The addition of information to separate systems is quicker rather than to a centralized system (Ngafeeson, 2015). The above discussion depicts that there are current issues and challenges faced by the healthcare system in HIE adoption and implementation requiring significant resources and efforts in healthcare reforms (Massoudi et al., 2016).

The central challenge for the healthcare organizations is regarding handling of variability in the diverse healthcare processes. With time, adding costs, complexity are acting as barriers in the implementation of HIE. To mitigate the HIE implementation and enhance the scope of use within healthcare organizations, FHIRs are being designed to facilitate interoperation and make healthcare information available to the healthcare professionals and systems. This system helps to solve the above challenge, as it is a simple framework for the extension and adaptation of the existing resources. This resource is an alternative to the paper-based and document-centric methods as there is direct exposure of discrete data elements into services. The basic elements like admissions, patients, diagnostic reports, medications can be retrieved, manipulated through the resource URLs. This resource is easy to implement as it uses web-based modern API technology suite as RESTful protocol that is HTTP based acting as fallback display for the patient clinical safety (Nilsen, 2015).

FHIR is a standard for the electronic healthcare information exchange that is built on the concept of resources. The basic units of modular components and interoperability are being assembled into working systems that can solve the administrative, clinical and infrastructural issues. It also has resources for the administrative concepts like healthcare providers, patients and organizations, clinical concepts like medications, health problems, diagnosis, care plans, financial problems. The specification is broken down into three basic components: general documentation, implementation, resource list. The general documentation demonstrates how resources are being defined giving background material that includes data types, formats and codes definitions. FHIR users can implement resources by using RESTful architecture programming interface acting as clinical documents or an architecture that is service-based. Finally, the resource list contains the administrative, clinical and infrastructural resources (Ruminski et al., 2016).

FHIR is defined as a framework for the extension and adaptation of resources that can be read by any kind of system despite of their development. The retrieval of extension definitions can also be done using FHIR framework as each resource carries HTML human-readable texts. This resource is based on foundations like JSON, XML, Atom, HTTP and OAuth that can be reused across the interoperability for the retrieval of history of a specific version or resource. This makes it easy for the individuals and healthcare providers to access it through many devices from cell phones to tablets to computers and allow application of third-party developers providing medical applications and easy integration into the existing systems (Lamprinakos et al., 2014). Moreover, it can also be used in cloud communications and sharing of EHR-based data among the healthcare systems and institutions. For example, patient being the resource has some important parts: local extension, human readable HTML and data content that is standard defined. Firstly, the there is resource identification and metadata followed by human readable summary, extension with URL to definition and finally standard data interpretation like name, gender, MRN, birth date and provider.

The key factors for the FHIR adoption are interoperability, consistent data, metadata capability and human readability. The practices like radiology, laboratory and pharmacy information are also being incorporated into the healthcare records enhancing interoperability (Mandel et al., 2016). This instant incorporation of these medical records requires standardized formatting and consistent language, however, FHIR intends to leverage the existing HL7 model by reducing the rework load. This resource along defines the discrete data elements that can be transferred between software vendor products and facilities. FHIR has metadata capability, as it is helpful in the accessibility of information that can be exchanged private and public payers in meeting the quality measures and in the forecasting of population health needs. Since, there is transfer of information requiring automated processing; it still provides human readable text for the instant use.

The main purpose of FHIR standard is to exchange information electronically acting as building blocks “resources” to make it easy for the healthcare providers to share and use clinical data without violating or compromising security. FHIR resource adoption has enormous benefits in the electronic health exchange. In healthcare, data is spread over multi-specialties and practices and so FHIR provide easy accessibility by all healthcare professionals in providing care to patients by creating a complete picture of all possible results and treatment plans. This is called immediacy of point-of-care treatment where a complete record helps to reduce the inappropriate lab work, tests and imaging while offering medication history for precise prescribing (Benson & Grieve, 2016). There is also improved reporting as healthcare providers can benefit from FHIR data in delivering higher levels of patient care and better health outcomes. There is better practice in the patient engagement techniques, treatment plans, community outreach and reduction in hospital admissions or critical care. There is also consolidation of data as the data serves the regulatory requirements and all healthcare analytics levels. Changing healthcare requirements like population health demand patients’ consolidation within the organization sharing common elements and therefore, it can be combined with the regional or national statistics. FHID resource provides a framework for the scalable data as it comes in the existing language version that will definitely not replace existing EHR system and save the incurring complete costs (Hong et al., 2017).

FHIR has extensive applications, although it is in the trail phase. It is considered a boon for the healthcare IT informatics and monitoring. It has well-documented and popular web-standards for the exchange of healthcare data that would reduce the barrier to entry for the healthcare professionals in the monitoring and insight derivation from patient clinical data (Walonoski et al., 2017). FHIR is the easiest way for the greater interoperability data mechanisms in the sharing among the healthcare organizations. It has the potential to change the way data is communicated among the healthcare spectrum providing better flexibility and timely access for the physicians and patients. FHIR is used for the development of a healthcare mobile application that aids in the effective management of electronic personal health records of patients through an interface that is accessible by multiple actors like pharmacists, doctor and patients as well. It has the potential to integrate in the application and client server side that help in the exchange of health information. It is a next generation resource application that provide framework for the current information exchange and web-based services. FHIR is being used by The Argonaut Project between various vendor and healthcare organizations and HL7 aiming to develop Core Data Services and first-generation API specification for the enables expansion of documents, electronic health records and health information on FHIR specification. In a similar fashion, The Health Services Platform Consortium (HSPC) is also collaborating with the healthcare organizations, academia and software vendors for the building of open platform on FHIR allowing rapid development in healthcare applications. FHIR application has tools for the sandbox for the development and developers (Hoffman et al., 2017).

FHIR is aimed at solving the long standing problems in the field of medical imaging. It has an ImagingStudy dedicated source that help to map parameters obtained from DICOM which are de-facto standards for the storing of medical images. It can be accessed via HTTP from the FHIR device or web. Metadata can be accessed separately on the resource. Moreover, the users can query data like patient name, UID and accessible for multiple images in a single command as compared to DICOM. This shows that FHIR can help to reduce the time, bandwidth enabled focus accessible to medical imaging data (Wagholikar et al., 2017).

FHIR has applications in payer systems as it face challenges regarding outdated processes and decreased margins. Payers look for patient-centred model that reduces costs, simplifies and modernizes the claim processing and automated mechanisms. In such cases, FHIR helps at every stage in the payer-enrolment, eligibility, claim and fund release. EligibilityRequest resources help to instantly check whether the patient is eligible under coverage. Coverage resource helps in storing the insurance plan details and through DiagnosticOrder resource, payers are aware of the eligibility of patient during care and incurring cost in claims. Claims can be handled through ClaimResponse and Claim resources. These resources offer easy accessibility as payers, providers and patients can track the working of the resource system. In a similar manner, FHIR resource supports the medical orders like cardiology, pathology with DiagnosticReport along with medical imaging. It has enabled lab systems that exchange data over HTTP with any kind of system and organizations. DiagnosticOrder resource of FHIR links contains all necessary elements that provide link to the laboratory reports. Therefore, this resource links all patient diagnostic orders as well as recorded observations of the patient in the form of links in the FHIR resource.

The healthcare market is embracing FHIR as many projects mentioned above are supporting this initiative. The SMART on FHIR being an open platform is developing app that is based on this resource application. It has the potential to be used as Internet and therefore, act as ubiquitous.   As it is well-known that EHRs do not provide functionality for the genomic information, so Precision Cancer Medicine (PCM) will be providing ready to use access to genomic data based on FHIR resource application. Substitutable Medical Applications and Reusable Technology (SMART) prototype visualizes the genomic data in real time and compared to the diagnosis-specific somatic mutations detected through PCR and comparable population data based on FHIR app.PCM is open source software for the physicians and clinicians for the presentation of patient at the population level in somatic mutations and cancer. SMART technology acts as an easy accessible programming interface that enables the FHIR app to run broadly in the healthcare organizations. HL7’s FHIR features and extensions provide native molecular profile information presentation (Alterovitz et al., 2015).

The main aim of the SMART-PCM app based on FHIR is to present the genomic health data at the population level to oncologists and patients in real time for the clinical practice. It provides seamless use and ease of access linked to the external knowledge within the FHIR app. Developers developed SMART PCM app through frequent input and continuous delivery cycle from clinical experts for the modelling of clinical genomic data. This app is accessed through iPad that authenticates the user to use the standard VUMC username and password. For example, if a patient has lung cancer harbouring KRAS p.G12C mutation, common occurrences are shown to avoid cluttering. This helps the clinician to view the fully labelled information through the charts and finally the “dive-in-details” helps to include the exact patient counts and full labels. Using that view, the user can link this to the external Gene Wiki content by just touching the desired gene of interest. In this way, SMART PCM, clinico-genomic app can be helpful in providing cancer mutation data at the population level and link to external knowledge bases. This model also helps in patient-centred approach and shared decision-making within workflow intermediary (Warner et al., 2016).  

The above discussion illustrates that FHIR resource provide extensive application in the electronic health exchange and in revolutionizing the healthcare ecosystem as a whole. FHIR is acting as boon for the interoperability and easier implementation of electronic health information exchange. It is a more updated and detailed version of HL7 meeting the current standards and challenges in healthcare. It has both machine and human readable data formats supporting RESTful architecture and web technologies. It might not be a one-stop solution for health IT, however, it has the potential to simplify the healthcare data exchange in a more technical and easy manner. However, its adoption is not an easy process as the scale is hard not because of the advanced technology rather vendor upgrade cycles. People have to go through unexpected code issues and most importantly, it is hard to fit into the daily use and standards of healthcare system. The issues and challenges like solving privacy, daily workflows, navigating politics and trust challenges might act as a hindrance in the implementation and sustainability of FHIR in the current health system. Economic value demonstration is the major hindrance in the integration and implementation of FHIR based apps (Kao & Liebovitz, 2017).

The future implications of FHIR may be impressive in improving the information accuracy level during health information transfer. It also has future value in the medical technology companies where FHIR based systems can be helpful in enhancing scalability, reducing costs and simplified interoperability. It can also be useful to the healthcare providers as it enable a clinician to access patient information from possible medical devices and further eliminates redundancies. These futuristic applications depicts that FHIR has enormous potential and sustainability in the healthcare ecosystem as it solves the issues of data privacy, improved electronic health data exchange, simplified interoperability, improved patient engagement and enhanced care (Milosevic & Bond, 2016).

While writing this research essay, I have experienced that EHRs are of paramount importance in the healthcare system and added to my existing knowledge regarding HIE. This research essay gave me an opportunity to know about the revolutionised FHIR technology that has enormous potential to overcome the current standard limitations in the healthcare ecosystem. I learned the advantages of FHIR applications like RESTful architecture, multiple paradigms, human-readability and open-sourcing through HTTP. While researching for the essay, I gained a lot of information about SMART PCM app. It is helpful in the presentation of cancer mutations at the population level and provide link to external knowledge for the clinicians. Concisely, FHIR is a next generation framework for the HIE systems.


From the above discussion, it can be concluded that FHIR leverages existing theoretical and logical models for the successful electronic health exchange and overcome issues of handling of variability in the diverse healthcare processes. It provides flexibility in electronic healthcare information exchange and overcome issues of time and resource investment like SMART PCM app based on FHIR. It also has future value in the medical technology companies where FHIR based systems can be helpful in enhancing scalability, reducing costs and simplified interoperability. Therefore, FHIR has enormous ability to revolutionize the healthcare ecosystem by solving data privacy, simplified interoperability, enhanced patient care and engagement.


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