HIT Perspectives: FAST: The Coalition Aiming to Strengthen the FHIR Interoperability Infrastructure

Health Level 7’s (HL7) FHIR (Fast Healthcare Interoperability Resources) standard is rapidly becoming the standard of choice to enable the exchange of clinical and, increasingly, coverage-related data. Its uptake will continue to accelerate because of work on functional use cases developed by various coalitions, including the HL7 DaVinci Project and the CARIN Alliance.

But the road from inspiration to implementation is not smooth. As coalitions pursue their respective functional use cases, they’re encountering similar challenges stemming from the existing hybrid environment. Just a few examples include how to locate and interact with the right payer without managing scores of one-on-one connections, how to mediate the range of versions and profiles in use, and how to integrate new FHIR exchanges with existing partners and infrastructure.

It became clear to early adopters that such challenges are common and needn’t be addressed over and over again within and across the individual functional use cases. Enter FHIR at Scale Taskforce (FAST), whose mission is to address those shared architectural barriers and gaps. FAST — convened at the request of industry leaders by the Office of the National Coordinator for Healthcare Information Technology (ONC) — is set to tackle key areas of common challenges and develop forward-looking potential solutions. The aim of these analyses is to address current barriers and establish an interoperability architecture to support FHIR adoption at scale.

Addressing technical challenges.

FAST is taking a Tiger Team approach to address these technical challenges that currently limit FHIR adoption. The first step in addressing these challenges was for the Ecosystem Tiger Team to analyze several functional use cases and identify common barriers. Although the analyses are focused on FHIR, they highlight common infrastructure issues that must be resolved to facilitate interoperability across various standards, technical platforms and use cases.

See the diagram below for brief problem statement descriptions for the FAST Tiger Teams and current proposed solutions still under development.

1. Directory. The need for accurate, complete and up-to-date directories of providers and payers is a pain point that FAST is addressing. Inaccuracies and gaps may limit access to care, delay speed to therapy and create complicated billing problems.
   Proposed solution: A national solution for FHIR Endpoint Discovery.
2. Versioning. Ensuring that everyone is on the same page with the respect to standards versions has been challenging since health information technology (health IT) standards were introduced as part of the Health Insurance Portability and Accountability Act (HIPAA). The problem has become even more complicated with the rollout of new standards, health care’s ubiquitous dependence on health IT, and use cases in which stakeholders adopt various versions of standards. Implementation guides need harmonization. Proposed solution: Supporting multiple production versions of FHIR.
3. Scaling. This issue has two components: the growing volume of FHIR-based transactions and the growing number and complexity of data exchange models. How do we make response times more predictable and consistent to better support real-time exchanges? How can standards be successfully implemented to support hybrid exchange models?
   Proposed solution: Requirements for FHIR RESTful exchange intermediaries.
4. Testing and certification. These are key components of ensuring that health IT systems are in sync with current requirements for FHIR adoption and deployment. How do we test and version across multiple stakeholders with varying degrees of maturity? How do we adequately test/validate consistently in a scalable environment? What are the minimum necessary requirements? While ONC currently has a health
   IT certification program, its focus is broader than FHIR and aimed at ensuring health IT systems meet federal requirements.
   Proposed solution: ONC FHIR testing and certification program.
5. Security. Protecting the security of health care data and their exchange are perennial problems that continue to be front-and-center issues affecting FHIR adoption. Factors include the amount of data being exchanged; the size and number of entities involved (solo practice vs multisite integrated delivery network); the need for permission to access and share data; and protections and responses to a variety of internal and external threats and vulnerabilities. Risk must be mitigated.
   Proposed solutions: Trusted client dynamic registration and token request.
6. Identity (patient and provider identity management). Correctly identifying patients is vital to correct billing, patient safety and high-quality health care. Because Congress prohibited the creation of a unique patient identifier using federal funds, there is no single way to correctly identify patients. As a result, payers, providers and others use complicated algorithms and patient-related information to identify patients and link them to their records. In addition, providers and patients must be correctly identified when real-time transactions are conducted.
   Proposed solutions: Mediated patient matching; collaborative patient matching; and distributed identity management.
7. Exchange. There are many technical challenges involved in consistently and reliably exchanging clinical data across a hybrid system, especially when partners may use one or more intermediaries for technical and business operations.
   Proposed solutions: Reliable routing and metadata access across intermediaries.

Importantly, these Tiger Teams aren’t working in a vacuum. Each of these proposed solutions has been presented to the FAST Technical Learning Community (TLC) to gain feedback and will be further vetted through smaller sessions with subject-matter experts for refinement and strengthening before they move to the next stage. Artifacts could come in the form of implementation guides, industry guidance or best practices.

Want to get involved?
Request to join a Tiger Team or participate in the TLC. You can sign up to join the FAST Technical Learning Community to get updates, provide input on technical and regulatory barriers, new use cases and potential solutions on the FAST confluence page. There also is a LinkedIn Group. •

Point-of-Care Partners (POCP) can also be a valuable resource on FHIR, program management of multistakeholder initiatives and related matters. We are the project management organization for Da Vinci and provide support staff for FAST (learn more on the FAST Confluence page). We are involved in several stakeholder efforts aimed at health IT standards and adoption. We’d be pleased to explain how these developments affect health IT in general and your organization. If you have any questions, contact me at dana.marcelonis@pocp.com.