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The Power of FHIRHow it is changing healthcare

W. Ed Hammond, PhD, FACMI, FHL7, FAIMBE, FIMIA, FIAHSIDuke Center for Health Informatics

Clinical & Translational Science InstituteDuke School of Medicine

Chair Emeritus, HL7 InternationalChair, US Realm

International HL7 Interoperability ConferenceWarsaw, Poland

October 22, 2019

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The Challenge

Health care is the most complex and confusing system in the world!

Rocket science is not healthcare.

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The Healthcare System Is Broken!

• Lack of communication• Between clinicians

• Between clinicians and patients

• Lack of interoperability

• Systems are siloed

• Systems are out of date

• Medical errors are the 2nd leading cause of death

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The Biography of HL7, Version 2• Courtship of niche vendors who wanted to create a Hospital

Information System with Best of Breed components

• Competition was IEEE group called MEDIX who wanted to build a more comprehensive model-based system

• Conception and birth at Hospital University of Pennsylvania

• Appearance argument between position defined with delimiters versus XML tags

• Implementation was mostly within hospital and by the people who defined the standard.

• Developers = implementers = users

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The teenage years of v2

• Small membership; fought for recognition; largely ignored

• With demonstrations at HIMSS, we began to attract more vendor membership. CDC became a visible and active member.

• Most implementation was in home grown systems.

• Flexibility provided through Z segments.

• Format and syntax was easy to understand.

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The adult years

• As the sharing of data increased and the electronic storage of data increased, so did the use of v2.

• Even now, v2 is still used in most hospitals in the US.

• v2’s sibling, Version 3, reverted back to the model-driven approach. The complexity was too difficult not only to use, but to understand.

• CDA provided a more templated approach that was easy to understand and implemented but was not flexible.

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The world is changing at an exponential rate!

Change creates new technology, new initiatives, and new stakeholders who are beginning to recognize that the future requires the use of standards to accomplish goals.

Change provides hope for the future!

Health and healthcare are undergoing more changes and at a faster pace than ever before in history.

And along came FHIR®

The timing was perfect.The stars were aligned!

AWS HAVEN

New stakeholders started to pay attention to FHIR.• Vendors• Payers• Pharma• Clinical Care and Research• Government• Patients

Enabling standards

• HL7 FHIR ®

• SMART ®

• CDS Hooks

REST (REpresentational

State Transfer)OAuth 2.0

“Give me a place to

stand, and a lever long

enough, and I will move

the world. ”

― Archimedes

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How is FHIR influencing the future?

FHIR is helping to open up the world. All these new initiatives and changes require the seamless flow of data. FHIR and its partner standards are opening the doors to enable the best health ever. At HIMSS 2019, FHIR was the talk of the town. Endorsements by ONC, CMS, CDC, HHS, the EHR vendor community and many others show the expanse of the impact of FHIR.

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FHIR is more than a standard! FHIR has created momentum for data sharing through interoperability.

Changes in perception of what FHIR isCanonical data modelCommon data elementsA data containerA data transportDocument/template standardControl of extensions

National Initiatives

• Precision Medicine

• Population Health

• Digital Health

• Mobile Health

• Patient-centered EHR

• Health Information

Exchange

• Big Data to Knowledge

• Consumer Engagement

• 21st Century Cures –

Apps

• Learning Health Systems

• Big Data to Knowledge

• Wearable Sensors/IOT

• Data Registries

• Computable Knowledge

• Virtual/Mixed/Augmented

Reality

Requirements• Data Liquidity

• Directed data sharing

• Health data standards

INTEROPERABILITY

• Describes the extent to which systems

and devices can exchange data and

interpret that shared data. For two

systems to be interoperable, they must be

able to exchange data and subsequently

present that data such that it can be

understood by a user.

HIMSS

INTEROPERABILITY

• Foundational interoperability

– the ability of one IT system to send data to another IT system

– Basic tier of interoperability

• Structural interoperability

– the uniform movement of healthcare data from one system to another such that the clinical or

operational purpose and meaning of the data is preserved and unaltered

– the recipient system should be able to interpret information at the data field level.

• Semantic Interoperability

– the ability of health IT systems to exchange and interpret information — then actively use the

information that has been exchanged.

– Highest level of interoperability

HIMSS definitions

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Challenges FHIR must address!

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Where is the patient’s data I want?

• Universal Person Identifier

• Common data model

• Unique and atomic data elements

• Consistency in how collected, how represented, units, structure

• Consistency terminology

• Quality checked with data entry

• Document identification

• Common templates

• Common transport

Problems to solve

• Patient matching – universal patient identifiers

• Common language – global acceptance;

everybody in; everybody use

• Increased data quality and trust

• Learning Health

• Increased Clinical Decision Support

• FHIR must support the right data for the

right patient at the right time for the right

reason.

Today everything is a source of data

Public Health

REQUIRES• Data Liquidity

• Data Sharing

• Data Standards

Policy, process, and focus change

• Policies of data sharing and patient-centric EHRs

create Big Data with clinical research producing

new knowledge.

• Site focus shift to the patient: telemedicine

• New types of data including behavioral, social,

economic, genomic, environmental plus clinical.

• Increased focus on patient/consumer

– Consumer engagement – population health

– Personalization of care – precision medicine

– Patient reported data

Behavior

Genetics

Socioeconomic

Environmental

Clinical

0% 20% 40% 60%

Mobile Devices• The ubiquity of smart phones has changed

communications between and among groups.

A virtual visit will replace an office visit.

• Wearable sensors will give real time data about

the person resulting in early interventions.

• Smart phone apps can be used for data

collection by text, check boxes, and

photographs with sufficient resolution to make

clinical diagnoses in many areas such as

dermatology.

• Smart phones can be used for education,

behavior modification, and more.

Brick and mortar institutions

will be replaced by virtual

healthcare systems.

• Big Data is a consequence of more things that create

data and more initiatives to merge data.

• For a single patient, we are talking about petabytes

of data; for a aggregated database of multiple

patients, we are talking about exabytes or more.

• Computable knowledge is an award of Big Data.

• Requires new and innovative methods of analyses to

create new knowledge

• NoSQL databases making their appearances

to provide higher speed necessary for analyses.

– Hadoop, mongoDB, others

Big Data and Its Impact

In 2017, we created 44

zettabytes of new data

daily.

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Bulk Data on FHIR

• The technology & policy for exchanging

records from an unlimited number of patients

or study subjects

• Developed cooperatively with Boston

Children’s Hospital / Harvard

• Supports data analytics for population health,

value-based care, clinical trial design and

pharmaco-vigilance.

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FHIR-based Projects at Duke

• Opioid control• Exercise physiology• Autism• Registries• Diabetes• Asthma• Rare diseases• Automation of sIRB process• Automation of Clinical Research• Community nNtworks

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FHIR Accelerator Program

Influencers of the future of FHIR

StandardDevelopers

Implementers Users

ArgonautDa VinciCARINGravity ProjectAgile GenomicsDigitizeDevices on FHIR

TranscelerateSync4ScienceSync4GenesGemini

Feedback of requirements

New Disruptive Innovation Requirements

• More sophisticated use of decision support

• Integration of images and enhanced use

• Biomarkers and genomics

• Social determinants of health

• Automation of Clinical Research

• Partnered APPs to tell a complete story

Decision Making

• The amount of data and the

kinds of data influencing health

and health care has far

exceeded the ability of the

human brain to make fact based

decisions.

• Therefore, most health care

decisions will be made by

computers and executed directly

without human engagement.

The Second Machine Age

• Cognitive Computing

• Machine Learning

• Deep Learning

• Artificial Intelligence

Roles for Avatars• Counselors

• Educators

• Companions

• Caregivers

Tomorrow’s Nurse

Companion for

aged persons

Robots and Avatars

Robbie

Sophia

A glance at the future

• Today’s surgeons use 2D images taken by X-

ray, ultrasound and MRI for surgical planning.

These images may not reveal complex internal

structures and complications in the heart’s

chambers.

• In a new project, surgeons use 3D printed

hearts to plan for difficult surgeries for patients

born with complicated heart disorders. The

heart models were created using the X3D Open

ISO Standard.

The art of the future possible

• The volume of data, the variety of data types, the increasing wealth of knowledge, and the ability to track disease and co-morbidities from start to finish will overpower the ability of humans to make informed decisions about health and health care.

• Computers will not only become the decision makers but will carry out the decisions directly.

• The role of the human clinician will change to being an interface between computers and patients, and that may only be a temporary step.

• Most humans will be replaced in healthcare systems.

• To resist is futile.

Fundamental Theorem

Source: Charles Friedman, UMich

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Thank You!