The Standard

HL7 on FHIR at HIMSS17 

With its world-class education, ever-expanding exhibition and exceptional networking opportunities, no other event brings the brightest minds in health and IT together like HIMSS17. More than 40,000 health and IT professionals are expected to attend to explore creative solutions to real-world challenges in Orlando, Florida at the Orange County Convention Center. 

HL7 is proud to support this annual event that helps health IT professionals find the right products and solutions for their organizations so that they can continue to transform health and lives through IT.

The Spectrum of Interoperability

In a world of polychromatic nuance, it’s interesting to see how often some individuals try to see things in black and white.  This tendency also seems to apply to healthcare data interoperability, as if any given product, organization or service can be classified as either “interoperable” or not. To me it’s absolutely clear that interoperability is a spectrum, which can only be aspired to as a matter of degree. 

Any given player may be viewed as more or less interoperable, but not wholly interoperable, because we live in such a heterogeneous world, with science and medicine continuously evolving. But no matter how you might personally think of interoperability, we can probably all agree that we still have a long, long way to go before we get there.

This is why we need events like Partners in Interoperability.  To achieve real progress, we must engage major stakeholders to stop and listen for awhile, and roll up their sleeves to make small incremental steps to move along that spectrum from the cold blue reality of the recent past to a warm, FHIR-y future based on improved interoperability. 

Partners in Interoperability October Meeting

The second Partners in Interoperability meeting was held at the Johns Hopkins Mt. Washington Conference Center in Baltimore on Oct. 18-19, an arcadian space conducive to deep thought.  As before, the meeting included a set of opening talks each day followed by breakouts focusing on the particular challenges of using FHIR among three distinct business communities:  Clinicians, Payers and Biopharma. 

Day 1

The meeting opened with a welcome from Dr. Christopher Chute, a long-time thought leader in the world of health data standards.  Dr. Chute evoked the history of the Great Baltimore Fire of 1904, which even predates the last Chicago Cubs championship, and led to the establishment of national standards for fire hose fittings.  The metaphor of a great fire being a pivotal event that burned down the old to create a new and improved place did not go unnoticed by the 60+ attendees at the event.

Next was a fast-paced set of five short insights on what FHIR means to the three represented communities, the health IT industry, and, above all, to the future of interoperability which we all aspire toward. 

The morning concluded with three lively presentations on FHIR’s promise and reality:

• Micky Tripathi gave an update on the Argonaut Project, which is close to completing its implementation guides for using the FHIR API and is already thinking about what to tackle next
• Ricky Bloomfield, MD gave an exciting visual talk on how FHIR is enabling several mobile apps to enhance patient care and interaction at Duke University’s Health System
• Sean Khozin, MD, presented on how the FDA is reinventing itself to capitalize on real world evidence from EHRs as well as multiomics big data sources – portraying several opportunity areas where FHIR can help advance the FDA’s mission.

Day 2

The second morning included recaps  from each of the breakouts, followed by one more set of plenary presentations:

• Avinash Shanbhag of ONC discussed the importance of FHIR to realize the goals of the next phase of Meaningful Use
• Titus Schleyer, PhD, of the Regenstrief Institute painted the vision that health information should flow like water, and demoed a FHIR app that allows patients to collect all their medication data from disparate health IT systems into one unified list
• The legendary Dr. Clem McDonald discussed and demonstrated an intriguing JSON-based forms generation toolset used by the National Library of Medicine that can be used, for example, with the Surgeon General’s Family Health History form.

Vote for the 2017 Top 50 in Digital Health 

Each year 50 of the leading entrepreneurs, investors, technologists, reporters, and providers dedicated to bringing technological advancements to healthcare are recognized at the Top 50 in Digital Health dinner hosted by Rock Health, Fenwick & West, Goldman Sachs, and Square 1 Bank. 

 
It's All About the Community

Someone recently asked me why I participate at HL7 and it didn’t take me long to answer: “It’s because of the community”. I wasn’t surprised when many other people answered the same in a recent HL7 Pulse survey.

My first experience at an HL7 Working Group Meeting

I first started participating just prior to the May 2008 Working Group Meeting (WGM) in Phoenix, AZ and I had no idea of the number people that I would be able to call friends and colleagues more than eight years later. I also had no idea of how much I would learn and grow from my participation! 

I felt so intimidated at that first meeting – it’s a very daunting experience for a first-time attendee. I think back to the conversations I had in Phoenix where I just hoped that I wouldn’t come across like a newbie. There was no way I was going to wear a pink ribbon. Looking back I realize how silly that was. I now tell first-time attendees that it’s perfectly okay to ask newbie questions and wear the pink ribbon!

Finding my HL7 legs

It can definitely take some time to find your way at an HL7 working group meeting – there are so may work groups and so many activities.  Luckily I had colleagues around me to help point me in the right direction. It actually took me almost 3 years to find my way to the Pharmacy Work Group and start participating on a regular basis. It seems like the Pharmacy Work Group should have been a no brainer for a pharmacist, but for lots of reasons it wasn’t.  I visited many work groups along the way, but once I started participating in Pharmacy, I think I found my HL7 legs. 

 
Climbing the Summit

When surveying the current landscape, I see a host of reasons to be excited about where our little collective of clinicians, researchers, academics, standards geeks, and industry partners sit at the close of 2016. Those who dabble in health informatics and health IT can look back over the last five to eight years and see a real transformation in how care is delivered, and we are on the cusp of doing the same to the clinical research enterprise.

Advances in the coming years

Public policy, with the aid of congressional support and impressive scientific advancement, has laid the groundwork for what promises to be an exciting next few years:

• EHRs are no longer the play toys of academic medical centers, with more than 98% of hospitals and 51% of office-based physicians using EHRs to deliver care;
• Congressional support for efforts like the Precision Medicine and Cancer Moonshot initiatives has reached a fever pitch, which fundamentally shifts conversations from “what is ideal,” to “what can be operationalized”;
• Data storage prices have fallen through the floor and computational speeds have gone through the clouds, with more organizations are leveraging SaaS-based platforms;
• Advances in genetic sequencing and gene-editing technology have changed how we understand and treat disease for generations to come; and
• A cultural shift that integrates patients, families and participants into care and research decision-making.

Reaching summits only to discover more

Now, the experience of wiring our healthcare system has taught us that once we reach the summit of one challenge, we are likely to see the summits of other, more daunting challenges.  This is a natural consequence of progress, which I measure by the complexity of our problems, not a list of our accomplishments. These complex challenges include:

• Continuing the march towards interoperability among different and disparate health IT;
• Identifying clinical utility of ‘omics’ data;
• Integrating useful omics data with routine clinical data; and
• Developing sustainable funding models, supported by data sharing and privacy-related public policies.

 
Many have asked the question: When are we going to realize the promises of sequencing the human genome?

Some argue the benefits are here. Others say not much has changed for healthcare consumers and patients. Some have invested in pharmcogenomic programs in the clinic, while there remain pharmacists who say the evidence still isn’t there. Patients see advertisements for cancer services that utilize genetic testing for targeted therapy, while others still claim most cancer patients don’t see any benefit.

We are in a period of both confidence and uncertainty, enough evidence and not enough evidence; let’s move forward with expanded testing and let’s only adopt a few tests, promises and warnings, a cost benefit or just increased cost.

Investments in Genomics Advances

In spite of the controversy, billions of dollars in investments are developing more products and services directed at healthcare consumers. This already includes direct-to-consumer genetic and genomic testing.

The precision medicine initiative is emerging as a high profile effort in genomic research and encourages patient-directed data ownership and sharing. It will be a major driver in building awareness and demand for genetic-based clinical services.

Tools from vendors—that range from biomarker and drug discovery to the clinical knowledge of diagnosis, risk assessment, and clinical meaning—are working toward advancing genetic-based care and realizing greatly improved outcomes.

Amidst this debate, many are committed to moving ahead to find clarity and the right path forward. In increasing numbers, people with day jobs are participating in mostly volunteer organizations to define and complete demonstration projects that prove both clinical utility to healthcare providers and significant value to patients.

Progress in Genomics

Internationally-focused organizations—like the Global Alliance for Genomics and Health (GA4GH), the Global Genomic Medicine Collaborative (G2MC), and US-based activities like the Genetic Alliance, the National Academies DIGITizE action collaborative, NIH grants like IGNITE and eMerge, and HL7 clinical genomics and Fast Healthcare Interoperability Resources (FHIR®)—are all making substantial progress. And there are many more related and critical activities I haven’t listed. Not only do we need to coordinate these activities, but we also need to bring together the diverse stakeholders in academics, research, technology, and national and global policy to see the vision move forward as well as how we’ll get there together.

 
Why FHIR for LATAM?
Latin America (LATAM) arrived on the scene late in terms of the use of earlier HL7 standards. HL7 Version 2 was created in 1985 but we (LATAM) did not begin using it until after 2000). HL7's Clinical Document Architecture (CDA®) was published in 2000 but we  began using it after 2005. HL7's Fast Healthcare Interoperability Resources (FHIR®) is being created now and we are starting to use it in LATAM. Two implementation guides have been developed in Argentina and Colombia; Chile is working on one. We can discuss the ‘we’ (as in ‘Who in LATAM’?), but the trend cannot be discussed.  Some countries in our region have yet to use any standard—there is NO installed base— why get stuck with stuff that’s 10 or 20 years old?

However, work is still in progress. While CDA Release 2 is good for document repositories, when it comes to mobile, what you can/should exchange is more discrete and granular. The choices will come down to how to use FHIR for examples such as:

• Only display allergies
• Only display the lab results for a graph. 

 
A little history

Studying HL7 history, our standards went from a plain text, replication/messaging-based paradigm in the 1980s to the current, Internet 2.0, resource-based paradigm. We also created document-based standards such as the Clinical Document Architecture (CDA®) Release 2 and SOA based standards like Common Terminology Services (CTS).

These 30 years of history gave us a good insight on what we need as standards users and developers.

What do we need as standards users?

People who implement and use standards want open access to standards and implementation guides. They need understandable and short specifications, off-the-shelf tools, reference implementations, friendly representation of information (instances), easy access to vocabularies, automated validation of instances, affordable education, a formal extension mechanism. 

Finally, they need examples, examples, and more examples. They need lots of examples!

What do we need as standards developers?

Standards developers have different needs. They want easy profiling with graphical user interfaces (GUI) and the ability to reuse templates. They also want one-click, automated publishing, validation and QA profiles, validation of instances, global profile registry, and ease of vocabulary binding.

January 1997: my first HL7 working group meeting

It was a dark and cold New England January in 1997 when I came down to my first HL7 working group meeting in Tampa Bay, Florida.

SGML 

I was invited to talk about Standard Generalized Markup Language – SGML – an object of veneration of a small cult that would give the world both HTML and XML, the engines of the World Wide Web and what came to be called ecommerce. To put this in context, the Web was just over 3 years old and XML was still a suckling infant.

It had been announced the previous month, in Boston, simultaneously with a talk on “SGML in Healthcare” by me and clinical co-conspirators, John Spinosa, Dan Essin, and Tom Lincoln. We finished before the XML folks and caught the final few minutes of what we knew meant a dramatic change in electronic information publishing and processing.

Prior to XML, the electronic text world was torn between the advocates of HTML (it’s simple, you can use it!) and SGML (it’s powerful, you can move mountains).  

For the HL7 Tampa talk, billed as a tutorial, I recruited two SGHappyML luminaries – Tim Bray and John McFadden – both Canadian, both showed up with winter colds. Tim was one of the prime movers behind XML; John later a reluctant convert. John had written the OmniMark language for markup conversion and he could actually make SGML work. Tim wrote one of the first programs to index the Web.

HL7 Ed to Go is here!

HL7 has launched an innovative certification preparation tool, HL7 Ed to Go, using the Qstream platform developed at Harvard Medical School. Based on game strategies and interval or “spaced” learning theory, questions are pushed at regular intervals directly to your mobile device.

This interval learning experience increases retention by 170% according to Qstream’s randomized clinical trials. “Brain science shows that even the smartest among us do better when there’s interval reinforcement and active recall of what we need to know,” according to Duncan Lennox, CEO and co-founder of Qstream.

Spaced Learning
Spaced learning has a long history in cognitive research, starting with Hermann Ebbinghaus, a German psychologist who in the late 19^th Century made an important discovery.  His research concluded that spaced learning, learning that is repeated at optimum intervals rather than one intense cram session, increased retention for long periods of time. He is credited with describing the learning curve as it relates to memory and forgetting. Unfortunately there was no practical way of implementing this learning technique until computers could be programmed to do the work of delivering and then re-scheduling the dissemination of information chunks at the appropriate intervals. Qstream has adopted this learning methodology and HL7 is excited to offer it as a new learning tool to help test-takers retain knowledge for greater success when preparing to take a certification exam.