Fast Healthcare Interoperability Resources
|Base standards||JSON, XML, RDF|
|Domain||Electronic health records|
Fast Healthcare Interoperability Resources (FHIR, pronounced "fire") is a standard describing data formats and elements (known as "resources") and an application programming interface (API) for exchanging electronic health records (EHR). The standard was created by the Health Level Seven International (HL7) health-care standards organization.
FHIR builds on previous data format standards from HL7, like HL7 version 2.x and HL7 version 3.x. But it is easier to implement because it uses a modern web-based suite of API technology, including a HTTP-based RESTful protocol, and a choice of JSON, XML or RDF for data representation. One of its goals is to facilitate interoperability between legacy health care systems, to make it easy to provide health care information to health care providers and individuals on a wide variety of devices from computers to tablets to cell phones, and to allow third-party application developers to provide medical applications which can be easily integrated into existing systems.
FHIR provides an alternative to document-centric approaches by directly exposing discrete data elements as services. For example, basic elements of healthcare like patients, admissions, diagnostic reports and medications can each be retrieved and manipulated via their own resource URLs.
The initial draft of FHIR, then known as Resources For Healthcare (RFH), was published on Grahame Grieve's blog in August 2011. The standard was adopted by Health Level Seven International (HL7) as a work item in September 2011.
In February 2014, HL7 published FHIR Release 1 as a "Draft Standard for Trial Use" (DSTU). FHIR Release 2 was published in October 2015, and FHIR Release 3 in March 2017, as the first "Standards for Trial Use" (STU) release. It included coverage of a variety of clinical workflows, a Resource Description Framework format, and a variety of other updates. FHIR Release 4, the first "normative version" was published on October 30, 2019.
FHIR is organized by resources (e.g., patient, observation). Such resources can be specified further by defining FHIR profiles (for example, binding to a specific terminology). A collection of profiles can be published as an implementation guide (IG), such as The U.S. Core Data for Interoperability (USCDI).
Because FHIR is implemented on top of the HTTPS (HTTP Secure) protocol, FHIR resources can be retrieved and parsed by analytics platforms for real-time data gathering. In this concept, healthcare organizations would be able to gather real-time data from specified resource models. FHIR resources can be streamed to a data store where they can be correlated with other informatics data. Potential use cases include epidemic tracking, prescription drug fraud, adverse drug interaction warnings, and the reduction of emergency room wait times.
Global (non country specific)
A number of high-profile players in the health care informatics field are showing interest in and experimenting with FHIR, including CommonWell Health Alliance and SMART (Substitutable Medical Applications, Reusable Technologies).
A variety of applications were demonstrated at the FHIR Applications Roundtable in July 2016. The Sync for Science (S4S) profile builds on FHIR to help medical research studies ask for (and if approved by the patient, receive) patient-level electronic health record data.
In January, 2018, Apple announced that its iPhone Health App would allow viewing a user's FHIR-compliant medical records when providers choose to make them available. Johns Hopkins Medicine, Cedars-Sinai, Penn Medicine, NYU-Langone Medical Center, Dignity Health and other large hospital systems participated at launch.
In 2014, the U.S. Health IT Policy and the Health IT Standards committees endorsed recommendations for more public (open) APIs. The U.S. JASON task force report on "A Robust Health Data Infrastructure" says that FHIR is currently the best candidate API approach, and that such APIs should be part of stage 3 of the "meaningful use" criteria of the U.S. Health Information Technology for Economic and Clinical Health Act. In December 2014, a broad cross-section of US stakeholders committed to the Argonaut Project which will provide acceleration funding and political will to publish FHIR implementation guides and profiles for query/response interoperability and document retrieval by May 2015. It would then be possible for medical records systems to migrate from the current practice of exchanging complex Clinical Document Architecture (CDA) documents, and instead exchange sets of simpler, more modular and interoperable FHIR JSON objects. The initial goal was to specify two FHIR profiles that are relevant to the Meaningful Use requirements, along with an implementation guide for using OAuth 2.0 for authentication. 
A collaboration agreement with Healthcare Services Platform Consortium (now called Logica) was announced in 2017. Experiences with developing medical applications using FHIR to link to existing electronic health record systems clarified some of the benefits and challenges of the approach, and with getting clinicians to use them.
In 2020, the U.S. Centers for Medicare & Medicaid Services (CMS) issued their Interoperability and Patient Access final rule, (CMS-9115-F), based on the 21st Century Cures Act. The rule requires the use of FHIR by a variety of CMS-regulated payers, including Medicare Advantage organizations, state Medicaid programs, and qualified health plans in the Federally Facilitated Marketplace by 2021. Specifically, the rule requires FHIR APIs for Patient Access, Provider Directory and Payer-to-Payer exchange.
Proposed rules from CMS, such as the patient burden and prior authorization proposed rule (CMS-9123-P), further specify FHIR adoption for payer-to-payer exchange. The CMS rules and Office of the National Coordinator for Health IT (ONC) Cures Act Final rule (HHS-ONC-0955-AA01) work in concert to drive FHIR adoption within their respective regulatory authorities.
Further, other agencies are using existing rule-making authority, not derived from the Cures Act, to harmonize the regulatory landscape and ease FHIR adoption. For example, the HHS Office of Civil Rights (OCR) has proposed to update the HIPAA privacy rule (HHS–OCR–0945–AA00) with an expanded right of access for personal health apps and disclosures between providers for care coordination. Unlike the CMS and ONC final rules, the OCR HIPAA privacy proposed rule is not specific to FHIR; however, OCR's emphasize on standards-based APIs clearly benefits FHIR adoption.
In 2020, the Brazilian Ministry of Health, by the IT Department of the SUS, started one of the world's largest platforms for national health interoperability, called the National Health Data Network, which uses HL7 FHIR r4 as a standard in all its information exchanges.
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