Interoperability Proves Critical as the Health Care Industry Advances Toward Value-Based Care

With the health care industry continuing to evolve toward a value-based care model, data interoperability has become more crucial. In this interview with Integrated Healthcare Executive, Mark Braunstein, MD, professor of the practice emeritus at Georgia Tech and board of directors’ member at Rimdi, Inc, describes how substitutable medical applications and reusable technologies (SMART) on fast health care interoperability resources (SMART-on-FHIR) started, its role in the health care application market, and current interoperability policies.

Can you discuss how SMART-on-FHIR was started, and where it stands now?

In 2011, HL7, the global health interoperability standards developer recognized the need to reconsider its approach based on modern technologies. That same year interoperability expert Grahame Grieve in Melbourne proposed a fresh look he called Resources for Health. The 2 efforts soon merged into FHIR designed to ensure that electronic health records (EHRs) and third-party applications would be able to communicate, and health data could flow between EHRs and other digital solutions freely and securely. The prior year the Office of the National Coordinator for Health Information Technology (ONC) funded an effort at Harvard to develop a standard framework for interchangeable health care applications called SMART. The Harvard group recognized the importance of FHIR and adopted it as the basis for their platform renamed SMART-on-FHIR. Together FHIR and SMART-on-FHIR offer an open, free, standards-based application programming interface (API) that facilitates the development of applications that can run freely within the health care system. 

Five years later, the 21st Century Cures Act addressed some of the ongoing challenges regarding interoperability and electronic health records (EHRs) by requiring certified EHRs to support patient-facing APIs to allow for increased data access, transparency, and interoperability across different health systems, EHR vendors, and third-party applications. In 2020, ONC and Centers for Medicare & Medicaid Services (CMS) issued the final rule to implement the act and designated HL7’s FHIR as the protocol of choice for API-based data exchange.

More recently CDS Hooks API, a new specification from the SMART group builds on FHIR and describes how EHRs can automatically invoke external platforms or apps based on rules stored within them. Now, with CDS Hooks, clinicians can have insights relevant to the patient’s specific clinical situation and within their EHR workflow based on data sourced within and from outside of it.

Can you explain the need for interoperability as the health care industry continues to advance?

Interoperability in health care is extremely critical—especially as our industry continues to move toward a value-based care model which inevitably drives us toward a continuum of care, including remote involvement by patients. At the same time, data interoperability has—and remains—a long-standing challenge that we must collectively overcome.

For example, interoperability is critical to giving providers the ability to see patient generated data in their EHR workflow at the appropriate time. This presents them with a more complete picture of an individual's health and clinical status, and also allows them to more quickly and efficiently make better decisions that improve cost efficient outcomes.

Will SMART-on-FHIR play a role in growing the health care application market?

Yes, SMART-on-FHIR is proving to be important to the growth of the health care app market. A recent study published in the Journal of the American Medical Informatics Association found a 20% jump in the number of EHR-integrated apps brought to market in 2020, including in newer areas such as population health, patient engagement, and telehealth. The interoperability mandates of the 21st Century Cures Act and the final rules from ONC and CMS issued in 2020, the healthcare industry should continue to lead to more FHIR-based apps devoted to important areas such as improved clinical process and workflows.

Can you discuss current interoperability policies and what they mean for providers, payers, and other key industry stakeholders?

As we have discussed, the 21st Century Cures Act enacted health care data access into law. To empower patients, it required certified EHRs to support patient-facing APIs. By essentially mandating FHIR it allowed for increased data access, transparency, and interoperability across different vendors and third-party applications. It also outlawed so-called “data blocking” to ensure access to EHR data.

The ONC and CMS final rules also mandated HL7’s FHIR as the protocol of choice for API-based data exchange.

These policies have made data sharing easier for providers, payers, and other key industry stakeholders.

Is there anything else you would like to add to the conversation today?

Until now, clinical decision support has primarily been an academic exercise. But growing support of CDS Hooks by EHR vendors will lead to development of CDS as a product in the broader commercial world.

With CDS Hooks, all patient data that comes from consumer apps, such as Apple watches and Fitbits, as well as other health care tools—like blood pressure cuffs and continuous glucose monitors—can be accessed through the EHR and have a timely entry point into the clinical workflow.

Thus, when an action is taken in the EHR—such as a physician writing a prescription—CDS Hooks-enabled platforms, with access to home-generated data, are notified and allow providers to respond appropriately. This clinical decision support ensures patients receive the best and most cost-effective treatment by taking into account all of their information and history—regardless of where the data was generated and is stored.

About Dr Braunstein

Mark Braunstein, MD,  Rimidi, Inc board of directors member,  is also a long-time advisor to the company. He is professor of the practice emeritus at Georgia Tech where he developed a unique health Informatics graduate seminar in which student teams work under the mentorship of a domain expert to develop a FHIR app to solve a problem they posed. He is currently serving as visiting scientist at the Australian eHealth Research Centre in Brisbane.  He recently published the second edition of his textbook Health Informatics on FHIR: How HL7’s API is Transforming Healthcare.