Recommendation for using HL7 FHIR for data sharing

Document revision history

Purpose and scope

This document describes a recommendation from the Norwegian Directorate of eHealth to use HL7 FHIR for data sharing to support semantic interoperability.

Applies to

Actors in the Norwegian health care sector that consider data sharing as a method for collaboration.

Recommendation

The basis for the recommendation are previous assessments by the Directorate, experiences from national and international projects, general adoption among suppliers and vendors, recommendations and use by ehealth authorities in other countries and other international standardisation organizations.

Data sharing

By data sharing we refer to the sharing of structured data by through common resources or services in real time. Collaboration through data sharing enables more dynamic information sharing between citizens and actors in the health care sector. Data sharing is when an actor requests or updates information from another actor. This allows multiple actors to collaborate on common information resources stored in one location, as opposed to message exchange where the same data is stored by senders and recipients of a message.

National data sharing is needed for:

• More efficient sharing and updating of a patient’s health and personal information between healthcare professionals
• Sharing of health and personal information between patient and health care professional personnel, for example by use of welfare technology or for providers of specialist health services
• Making interfaces from national common solutions available to third-party application/service providers

The target architecture for data sharing in the healthcare sector [1] describes different areas of application where data sharing is used for collaboration. This includes cases where healthcare professionals need to query, register or update health data in national ehealth services, such as Summary Care Journal [Norwegian: “Kjernejournal”], and query register and services for basic data [Norgegian: “Grunndata”]. Other use cases described in the target architecture are cases where data sharing is used to give citizens the ability to participate and get access to their registered health data from central/national registries/journals, and their usage.

Data sharing is typically realized through an Application Programming Interface (API). An API is an interface to a software where specific parts of it can be activated (run) from other software through calls to the interface.

See also reference architecture for data sharing [2.]

About FHIR

HL7 FHIR (Fast Healthcare Interoperability Resources) is an open standard from HL7 International. FHIR was developed to meet the demands for more efficient and flexible development of standards-based integrations and better support for integration with modern technology such as mobile and cloud services. FHIR standardises the use of REST and the information resources for data sharing between clinical systems, but the FHIR resources can also be applied to message exchange and document sharing.

FHIR for data sharing enables reuse of APIs across systems. By exposing data from a clinical system to common standardised APIs, it enables other clinical systems, applications, equipment or registries to use a standard interface, regardless of which system they retrieve the information from. This is independent of whether the consumer application is internal or external to the healthcare actor.

FHIR supports an agile standardisation process which enables easier, faster and more flexible development of interfaces that also scale well.

One of the greatest benefits with FHIR is that it is easy for developers to use, however, to achieve interoperability in the long-term, it is necessary that FHIR is implemented uniformly, and in a harmonized way across the healthcare sector.

There will often be a need to adapt FHIR resources to the context in which they are to be used. This could local, regional, national and international levels. It’s important to coordinate national FHIR development with international efforts.

Normative status

Version R5 of HL7 FHIR was published in March 2023, where 15 resources in the standard are normative. In order to achieve normative status, several requirements must be met for FHIR. For instance, a resource must have at least five independent implementations in at least 2 countries. In addition, a certain number of ballots must be completed. Many resources are at lower maturity levels.

National coordination

FHIR is a flexible standard and represents a framework that needs to be adapted to the national context. FHIR has built-in flexibility so that the standard can be customized, and elements can be added for local requirements. This means that the standard can cover a wide range of local requirements, and at the same time represent an internationally standardised format.

To ensure national semantic interoperability, there is a need to coordinate the use and adaptation of the standard at the national level. Such national coordination is needed to enable the reuse of APIs.

The cooperation model for international standards [3] describes the roles, responsibilities and processes in the healthcare sector in the working process to utilize international standards in Norway. The cooperation model should be the baseline for national coordination of the use of HL7 FHIR in Norway.

Norwegian core profiles and sector profiles

Core profiles for central HL7 FHIR resources have been developed. These core profiles are recommended standards in the Reference catalogue for eHealth [4]. The core profiles define adaptaions for use in Norway, and can be used directly or further developed for specific use cases and interfaces.

A national domain profile adapts FHIR resources for collaboration in a specified application area. The domain profiles are information structures that can be used across implementations.These profiles can be applied directly or be adapted as needed [5].

Why FHIR is recommended for data sharing: Data sharing as an integration model

For several years, data sharing based on open APIs has been the preferred integration model among the major international technology companies, for instance in the financial industry. Data sharing is now being adopted on a broader scale also in healthcare, therefore there is a need to standardise the information shared through such APIs.

Examples of HL7 FHIR usage

There is great interest and increasing number of implementations with FHIR for data sharing both nationally and internationally. This is primarily because the standard is easy to use and covers new communication needs related to data sharing with for instance mobile technology and cloud services.

The first FHIR interfaces in Norway went live between EHR and two clinical systems at Oslo University Hospital in 2015.

On a national level, helsenorge.no, The Welfare Technology program and SFM (Central Prescription Module in ePrescription solution) have FHIR interfaces in production. Other examples where FHIR is used is in Patient testresults (Pasientens prøvesvar), the Health Data Program and the Health Platform (Helseplattformen). In addition, several regional projects have used FHIR for their implementations.

The EU is committed to use FHIR as a core standard for new services [6], in the infrastructure for exchange of health data for primary use, with MyHealth@EU. FHIR will be used for representation of content and transfer of health information regarding hospital discharge report, laboratory reports and medical imaging. A transition from CDA to FHIR for existing services (e-prescription and patient summary) will be considered at a later point in time.

In the US and UK, the health IT industry adopted FHIR early, and has worked with the authorities to develop FHIR as a national standard for data sharing. Major technology providers such as Apple, Google, Amazon, IBM, Microsoft and others support this health information exchange standard.

CEN defines FHIR as an exchange format in new standards such as International Patient Summary. PCHA (publisher of Continua Design Guidelines) and IHE have partnered to use FHIR as the exchange format in their standards.

In "Innovation Insight for HL7 FHIR" (August 2018) [7], Gartner states that FHIR should be a key component for healthcare companies who want to improve the interaction ability between applications and third parties. Gartner believes that FHIR will become the global “lingua franca” for the healthcare sector. As several global organizations like Cigna, Optum and UnitedHealth Group incorporate these standards to support American operations, FHIR-based data exchange will spread across healthcare systems around the world.

Previous recommendations on FHIR

This recommendation on the use of FHIR for data sharing reinforces previous recommendations on FHIR made by the Norwegian Directorate of eHealth (Assessment of International Standards (2016) [8].

The conclusion in 2016 was that FHIR could be considered for new use cases that needed to share structured data. Due to the low maturity of many resources and limited distribution, only limited use in simple use cases was recommended at that time.

In 2018, the Directorate performed an assessment of relevant standards that can be included in a framework for common information models [9]. FHIR was recommended as a representation of information models intended for exchange.

References

See also Anbefaling om bruk av SMART on FHIR [Norwegian version of the document]