This workshop was developed in close collaboration with the OPEN DEI project.
On 12 May 2022, EHTEL held a Transformation track webinar that explored the data exchange for health standard, HL7® FHIR®; what FHIR® brings in terms of return on investment; how it is used; and the challenges to be faced when using it. Overall, the webinar explored how both public and private players can benefit from using FHIR®. The webinar provided the perspectives of both industry and public authorities on all these questions.
HL7® FHIR® is becoming the de facto reference standard for data exchange in the health sector. New products, services and architectures are developed with HL7® FHIR® resources, and new use cases are created every day.
Today, a whole eco-system of small and medium-sized enterprises (SMEs) and APPs developers is built with and around HL7® FHIR®. But more than that – public authorities are increasingly relying on HL7® FHIR® to organise the exchange of data between public institutions and between private and public institutions.
HL7® FHIR® stands for Fast (to design & to implement) – Healthcare Interoperability Resources (as building blocks).
Its manifesto is ambitious. It focuses on:
- targeted support to common scenarios,
- the capability to leverage cross-industry web technologies.
It also aims to support multiple paradigms & architectures and demonstrate best practice governance.
Return on Investment from FHIR®
Return on Investment, when using FHIR®, differs for private and public players.
While for a number of companies, HL7® FHIR® provides an outstanding business opportunity, the perspective of public authorities can be very different.
From a business perspective: Given the multiple priorities involved, the question of Return on Investment is critical. Essential too is the capacity to anticipate costs that are one-off, evolving, or associated.
From a public authority perspective: To promote strategic services, the priority for public authorities is to have the standard correctly defined, documented and applied swiftly and consistently in their own ecosystem. To achieve this, they need appropriate mechanisms that assure both stability and controlled evolution. Given the anticipated future multiplication of use cases (including those which will have to cross borders), global alignment is also vital.
What FHIR® has to offer
HL7® FHIR® can be used in different architectures and with various interoperability paradigms.
From the presentations made at this OPEN DEI-supported webinar, it became clear that the influence of HL7® FHIR® goes beyond the implementation of specific use cases; at a higher level, it also directly influences Representational State Transfer (REST)-based architectures that have been developed to support multiple use cases. (REST is a style of architecture for building applications, such as for the Web, Intranet, and Web services. It is a set of conventions and good practices to be respected. The architecture uses the original specifications of the HTTP protocol).
Furthermore, many organisations are under stress. Inside them, a much larger number of people than previously need to acquire HL7® FHIR®-related expertise. Healthcare organisations need FHIR® knowhow for their logical models and how these models fit with implementation. Private companies need the knowhow of practical FHIR® profiling and technical implementation.
HL7® FHIR® in use
Challenges related to the use of HL7® FHIR® depend on the size, volume, and complexity of organisations, and what systems they currently use. This occurs inside the wider context of the European Health Data Space development.
For small and medium-sized enterprises (SMEs) developing new products and services: HL7® FHIR® is an obvious choice. The HL7® FHIR® standard is beginning to be used not only for health resources representation and storage, but also as an instrument to enable seamless integration of Internet of Things devices.
For major players, whether public or private: The transition to HL7® FHIR® raises several questions. The players need to take decisions on the opportunity either to move to a “HL7® FHIR® upgrade” of their previous products or services or to create the necessary bridges, and this is costly. In most cases, a cautious, ad hoc and opportunistic approach to the problem can be observed. Clinical needs will decide what are the priorities to be tackled.
In many European countries, after a long period of preparation, national or regional data sharing infrastructures are now finally in place and operational. In the short term, adaptation to the FHIR® paradigm is thus likely to be mainly incremental.
Yet this does not mean that data exchange through messaging has disappeared: many use cases require making use of both sharing and messaging. With messaging increasingly being HL7® FHIR®-supported, public authorities face the dual challenge of maintaining and developing both universes.
HL7® FHIR® adoption will also have a major impact on cross-border services both for primary and secondary uses of data. It is thus an important enabler for the creation of a European Health Data Space.
The bottom-up challenges of FHIR® implementation
HL7® FHIR® is already 10 years old, but it is still very much in the making.
Public authorities and companies today often use HL7® FHIR® extensions to fulfil their requirements.
FHIR® is different from HL7v3: only the data on which a consensus has been reached is profiled in the current international FHIR® specifications. Therefore almost all projects need to make local extensions. Using extensions in HL7® FHIR® is thus of course a need, not an embarrassment. Profiling in FHIR® emerges bottom-up from each project, and not top-down as was often the experience with earlier HL7® standards. The use of these extensions is, however, often required as mandatory by the public authorities concerned.
HL7® FHIR® is therefore subject to a continuous refinement and improvement process that follows an incremental, iterative approach. Some parts of the standard are normative; others are less mature.
In general, the use of extensions is not a sign of immaturity, but is a standard design choice. Extensions are also used with normative resources. If not properly managed and governed, there is of course a risk that diverging extensions will impact negatively on HL7® FHIR®-based implementations.
A range of activities to support HL7® FHIR® use is needed.
Making documentation publicly available and easily findable is crucial. Collaboration and coordination are also important. Policy makers, competence centres, European institutions, software vendors, standard development organisations, and customers must collaborate and coordinate at different organisational, sectoral, regional, national, and European levels.
Finally, cost-handling matters.
The costs associated with the standardised HL7® FHIR® implementation guides development and the management of a transition plan to adopt FHIR® are today mostly supported through public money. Private investment is usually mainly limited to pro bono work of HL7® affiliates. Each private company may have invested in its own HL7® FHIR® data model or API, but having different APIs is not good practice for national and international interoperability.
When confronted with the need to ensure the timely, quality and consistent implementation of new priority services, public authorities develop different incentivisation models to engage industry, either by subsidising it directly or by rewarding users who use only compliant, certified solutions. This selection may at times also represent an obstacle towards a rapid and generalised use of the standard.
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