The future of healthcare systems lies in open standards that free data from traditional, stand-alone silos and make it available to the many applications that need it. But how are we going to reach that future?

Realistically, we have two options: open Electronic Health Record, better known as openEHR and Fast Healthcare Interoperability Resources, or FHIR. I’m not going to argue that one is better than the other. They both have advantages and disadvantages and they will both have a role to play in the digitisation of the NHS.

However, it sometimes feels like openEHR has become the focus of attention in the UK and I’d like to see more debate about the role of FHIR and open platform architectures that use FHIR to natively extract, store and re-export data to applications.

This is the model that Alcidion uses in its Miya Precision platform, and I assert that it has some benefits for innovative suppliers, trusts and Integrated Care Systems.

OpenEHR and FHIR

OpenEHR and FHIR both aim to address a long-standing problem in healthcare, which is that conventional healthcare systems tend not to share information – to interoperate – with each other.

Conceptually the most important difference between them is that openEHR uses multi-level modelling while FHIR adopts an 80/20 rule. In other words, openEHR operates with a stable reference information model, that sets out to capture every use case for data in the medical world and archetypes and templates that enable it to be used and re-used in the real-world.

While FHIR is built from discrete resources that cover 80% of the data elements that are used in existing healthcare systems. This leaves the remaining 20% for specific use cases that can be customised, extended and handled by FHIR profiles.

The obvious attraction of openEHR is that it paves the way for disparate systems to operate to a pre-determined standard thus claiming ultimate interoperability. It also allows organisations to build a stable representation of their data and to use it to build and manage their own healthcare system from the ground-up.

However, openEHR requires a strong commitment from organisations and clinicians to maintain and extend the underlying model, while the need for the whole openEHR community to move forward together can make it difficult to implement localised changes.

FHIR is less grand in scope and is a lot easier to use. Indeed, FHIR resources were built to make it easy to integrate disparate systems. They are easy to understand and to transmit over well-understood network protocols and modern, web-based technologies.

This makes it easier for suppliers to build applications that can ‘plug and play’ with other systems and for trusts and ICS’s to adopt them to deliver the changes that matter most to them.

FHIR: not ‘just’ a messaging standard

So, why isn’t there more discussion of the role of FHIR in UK healthcare? I think one issue is that FHIR is often catalogued as a ‘messaging standard’ when it is far more than that.

FHIR resources represent generic clinical data models and templates containing data elements for different types of clinical and administrative functions in healthcare settings. There are approximately 150 FHIR resources for concepts such as ‘patients’, ‘encounters’, ‘observations’, ‘medicines’, ‘allergies’ and so on.

All of these are actively developed and nurtured by the HL7 Organisation, so they can be used as a model to store data as well as to exchange data. This means it is possible to use FHIR as the basis of an open platform architecture; one in which data is extracted, stored and re-exported as native FHIR messages.

Alcidion was an early adopter of FHIR and our Miya Precision platform is unique in using this model. In passing, it means we separate the data layer from the application layer, which is what the UK government, NHS England, and the transformation directorate that has absorbed NHSX, say they want to do.

Benefits of FHIR thinking

There are some significant benefits to adopting FHIR thinking. One is that it works well for the microservices architecture approach that Alcidion has also embraced for Miya Precision. Because FHIR supports RESTful architecture and modern web standards, it’s possible to create business-focused applications that can be deployed at speed, while remaining highly configurable.

Native FHIR data extract, storage and re-export also offers significant benefits when it is used to power an event bus that orchestrates communication between different micro-services and applications. The data store in the Miya Precision platform is constantly being updated with information and analysed in real-time for variations in a patient’s condition.

This enables alerts to be sent to Alcidion’s suite of mobile first applications to improve patient safety (Miya Observations) and operational efficiency (Miya Flow). In effect, it not only separates the data layer from the application layer but makes the data layer active and useful.

At the same time, the universal event bus makes it easier for new and innovative suppliers to join a trust ecosystem; without having to interact with the API layer or facade that traditional vendors put over their systems or adopt the entirety of the openEHR conceptual framework.

This last point should appeal to forward thinking trusts and ICSs. If you want to store information from disparate systems at an ICS level and to use it in new pathway apps and analysis, without going ‘full openEHR’, you should be thinking about doing it in FHIR native format, so you get mature interoperability from the outset.

Let’s FHIR up a debate

The NHS needs innovation and it needs to adopt approaches that will allow it to reach that open future in order to make the most of it. That means there’s a big market out there and plenty of scope for both openEHR and FHIR to demonstrate their value.

But it also means we shouldn’t let a single philosophy of open standards drive our product engineering. Instead, we should remain focused on what we all want to achieve, which is not just a longitudinal health record, but one that helps clinicians to focus on patient safety, patient care, and patient satisfaction.

I think that means we need to kindle that conversation about FHIR, because FHIR can lead us to the point at which, as a colleague of mine puts it, we’re doing ‘the cool stuff’ – faster.

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The Care Connect interface links Orion Health’s pioneering integrated digital care record and the Cyber Media drug and alcohol system, Theseus, which is used by Bristol City Council. It was developed to reduce the risk of duplicate prescriptions being issued for controlled drugs, which can lead to overdoses and other serious incidents. Dr Mike Taylor, lead GP at The Homeless Health Service in Bristol, said: “GPs working ‘in hours’ or ‘out of hours’ now have a reliable, quick, efficient way of knowing whether the patient in front of them is receiving opiate substitutes from drug workers outside practice-based care.

Clinicians in hospitals can also be aware of this source of prescription. This has real potential for saving lives and reducing drug-related deaths.”

The link is also significant because it makes NHS South Central and West Commissioning Support Unit (SCW), which supports Connecting Care, one of the first organisations nationally to use the Care Connect FHIR APIs championed by NHS Digital and INTEROPen.

NHS England commissioned the development of Care Connect APIs to make it easier for health and care services systems to share information, using HL7 FHIR, a new standard for exchanging healthcare information electronically.

Emlyn Jones, technical lead for the Connecting Care programme said: “Our long-term goal is to create a consolidated list of medications for each patient, and this is the first step in doing that. So, we were looking for an interface that we could re-use, and the FHIR profiles felt like a good fit.

We spend a lot of time in the tech community talking about FHIR, and this seemed like a good opportunity to try it. FHIR is polished by being used. By doing things, we get them right.”

To support timely availability of the OST medications, the Theseus system, presents Connecting Care with an API that the Orion Health Clinical Portal calls to find out if a listed patient has been prescribed controlled drugs.

Fran Draper, senior project manager and engagement lead, Connecting Care Programme said: “This was a very rapid project; from design to go-live took just seven weeks.

It was an exciting project to work on, but it was just dipping our toes in the water. We want to go further, and to use this work to get into the technology of the twenty-first century and beyond.”

The Care Connect FHIR API initiative was started in 2016 and is at the heart of INTEROPen’s vision to create nationally defined HL7 FHIR resources and interaction patterns, to simplify integration and interoperability within UK health and social care. NHS Digital are supporting INTEROPen to foster collaboration between industry, standards bodies, informaticians, terminologists and health and care providers to define FHIR resources tailored to the NHS which support interoperability between health and care systems.

Orion Health, which provides the technology that underpins Connecting Care, was one of the founder members of INTEROPen. The INTEROPen initiative can help support the vision of the secretary of state for health and care, Matt Hancock, by introducing the data interoperability standards he wants to make sure that the IT systems used by NHS staff can “talk to each other.”

The work in Bristol puts SCW and Orion Health in the vanguard of this national agenda. Dr Amir Mehrkar, GP and co-chair of INTEROPen, said: “Members of the INTEROPen collaboration have co-produced a set of national CareConnect FHIR profiles over the past year, so it is wonderful to see real implementation of these interoperability standards in the service.

“There is a lot more work to do but this is an important example of how sharing clinical information stands to make a real difference in patient safety.”

Connecting Care is one of the longest-running and most extensive integrated digital care records in the country, enabling secure, instant view only access to health and care records for around 6,000 professionals working in Bristol, North Somerset and South Gloucestershire.

Role-based access is built into the Orion Health technology that underpins the project, so professionals can only see the information they need to do their jobs. Citizens can opt-out at any time.

Every new interface added to Connecting Care goes through a rigorous information and clinical governance control process that can include discussion by the Connecting Care board.

The new FHIR supported interface is already live in Bristol, where it can be viewed by staff working in 27 organisations, including 85 GP practices, NHS hospitals, mental health and out of hours services, social services, paramedics, charities and hospices.

The next step will be to extend it to the other areas using Connecting Care. Gary Birks, general manager, UK and Ireland, Orion Health, said: “We are proud of our association with Connecting Care, which is undoubtedly one of the most-cutting edge integrated digital care records in the country.

Orion Health was a founding member of INTEROPen so we were particularly pleased that SCW decided to use a Care Connect FHIR API for this important project. We continue to work with SCW on developing leading edge interoperability and look forward to more successful delivery in the future.”

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The APIs will be available in a rolling programme right across all Care Alliance products – including shared care records, child health, EPR, and social care solutions.

First to be launched is Graphnet’s open interoperability platform, offering FHIR APIs to the CareCentric shared record software. CareCentric is the country’s most widely-used record system, bringing together information from right across primary, secondary, community, mental health and social care sectors and information held in Personal Health Records (PHRs). It underpins England’s biggest and most high-profile record systems, such as those in Greater Manchester, Berkshire, Hampshire, Cheshire and Buckinghamshire.

Graphnet’s interoperability platform will give customers secure access to the wealth of real-time and near real-time information held in the CareCentric shared care record and provide a standard for integration with other healthcare applications. It will be available to the all company’s shared record customers, including Local Health and Care Record Exemplars (LHCREs).

This will allow for record sharing across organisational boundaries, linking one shared record system with another and creating a framework for open application development. It will also enable the CareCentric shared record to become an integration and open application platform, encouraging innovative new apps and new uses to help drive improvements in patient care and in managing the health of a population.

The System C & Graphnet Care Alliance FHIR programme will consist of a rolling sequence of releases. Next off the line will be social care, child health, vitals, clinical collaboration, alerts, connectivity for third-party patient facing apps, and a range of API packages for the Care Alliance’s PAS, EPR and clinical systems.

For social care, Liquidlogic is generating the nine FHIR messages necessary for hospital assessments, discharges and withdrawal notices. These are being implemented with four councils by March 2019.

“Graphnet and System C’s products have always been highly interoperable. We interface or interoperate with over 2,000 deployed systems across the UK,” said Dr Ian Denley, joint CEO of the System C & Graphnet Care Alliance. “What FHIR brings is a national standard set of messages for use right across the NHS and social care, and this will be a major step forward in delivering the joined-up care needed to improve patient outcomes.

“We were a founder member of HL7 UK in 2000 and we believe that the progressive release of FHIR standards by NHS England will have a similar positive impact on APIs as HL7 did on standard interfacing.”

The large-scale adoption of FHIR is being delivered on top of System C and Graphnet’s internal APIs which are already widely used for integration across the Care Alliance product range, and which will be brought into line with national standards as they are released under a standard licensing arrangement.

The FHIR programme will provide an extensive package of FHIR services and a robust and secure framework for open access. This framework includes:

• A profiles library which will be published internationally so that software houses in the UK and across the world will be able to develop products connecting to System C and Graphnet solutions. The APIs will be based on FHIR standards and conform to PRSB/NHS Digital/INTEROpen profiles.

• Test sandpits and accreditation services to ensure that applications connected to services are well-behaved and secure
• Developer and user support services

All of these services will be tested with the initial set of APIs released for licence by the end of the year. The entire rollout programme will take around 24 months to complete.

Brian Waters, chief executive of Graphnet, explained that Graphnet FHIR support builds on its existing APIs, originally developed for internal use. “This is a well-proven path for us. The FHIR messages are simply an extension of our work of the last three years. We are now finalising the delivery schedule for the FHIR resources and will release these in a rolling programme as and when they are formalised and published by NHS England, with the first releases available this financial year.”

Beverley Bryant, chief operating officer at System C & Graphnet Care Alliance, said: “The drive for interoperability between our systems and third parties has been steadily growing as our users across health and social care expand their adoption of health technologies. The FHIR programme will offer customers an extensive package of FHIR services and a robust and secure framework for open access as part of the product catalogue.”

“This move to FHIR, and the very clear commitment to interoperability from the Secretary of State Matt Hancock, will bring a welcome sense of order to the market.”

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