Predictions for Health IT: FHIR Is the Spark for Innovation in 2021

By Nick Hatt, senior developer, Redox

I will not be the first nor the last to use the Gartner Hype Cycle as a mental model to analyze the trajectory of HL7 FHIR® . Now here we are in 2021, in the midst of a global pandemic, and I'd say we're firmly entrenched in the Trough of Disillusionment. Part of that may be the fact that much of the data sharing for combating the pandemic has fallen back to HL7 version 2

(HL7® v2), a 35-year-old standard. It may also be that federal rulemaking from the 21st Century Cures Act landed this year and FHIR is actually being used to build things. Finally, it may be the sheer complexity of the specification and the ever-expanding set of resources. Thankfully, the Slope of Enlightenment comes next - right?

FHIR (Fast Healthcare Interoperability Resources) is not the cure for COVID-19 data reporting needs, but that is not necessarily due to the FHIR specification itself. In the early days of the pandemic, numerous efforts were started to build FHIR implementation guides around the problems that many countries were dealing with. The SANER implementation guide is one such example for reporting inventory of things like ICU beds and ventilators, and the Logica COVID IG handles exposure, testing, diagnosis and treatment. Ultimately, CSV files won out as the predominant method of exchanging metrics - over FTP or even manually uploaded. Most public health departments still rely on HL7v2 for lab reporting, and that too has taken precedence over FHIR. There are a few key takeaways from this: FHIR supports the rapid development of specifications - essentially an order of magnitude faster than previous standards (which would be published as a PDF), but those who need to implement the standards (IT workers at individual health systems) can't move as quickly as the implementation guides can be published. The existing health IT stack is simply not ready to take FHIR and do creative things with it, especially when CSV files and Excel are alternatives, but we may well see the FHIR stack become more and more relevant in 2021.

Federal rulemaking in 2020 was quickly overshadowed by the gravity of the pandemic, but the rules remain in effect - effectively requiring EHR developers and payers to develop and release FHIR APIs in the next two to three years. FHIR products from Google to AWS and Microsoft all reached major release milestones this year in anticipation of capturing some of the developer market. Despite this, none offers a turnkey solution to meet all of the requirements. In addition, these cloud offerings are still outside the comfort zone of organizations that currently run stovepipe legacy systems and that are on the hook for meeting the rules. Again, this mismatch of solutions is not a problem with FHIR, but it does bring the name down with it.

The FHIR specification is nearing 150 resources, of which the number that are "normative" (in their final state) can be counted on two hands. This contrast between "production ready" and "work in progress" is not optimized for new developers and leaves a space for industry to fill - offering products or consulting services to help make sense of it all. This development will ultimately give rise to the Slope of Enlightenment around FHIR. I firmly believe that products and services being launched in 2021 are essentially just right in terms of where they are coming along in FHIR's trajectory in the hype cycle.

I feel confident that the strength of the FHIR standard is well-established, as evidenced by being blessed by the US federal government. The takeaway from efforts to solve COVID-19 with FHIR should not be measured by their efficacy, but rather by the speed with which they were developed and published - a game changer in juxtaposition to previous standards. At this point, FHIR is an imperfect yet critical piece of the public good that will sprout many new innovative ideas in 2021. If we are truly in a Trough of Disillusionment, there are very positive indicators that FHIR will emerge from it and that 2021 should be a banner year.

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About the Author

Nick Hatt is a senior developer and in-house "FHIR-whisperer" at Redox, which reduces the barrier for tech implementation within healthcare organizations by streamlining the integration process through interoperable networks. Nick focuses on support for standards and EHR vendor APIs. Before joining the Redox team, Nick was a developer on the interface team at Epic.