Schlag and Froth: Argonauts Navigate Between Heavy-weight and Light-weight Standardization (Part 1 of 2)
You generally have to dwell in deep Nerdville to get up much excitement about technical standards. But one standard has been eagerly followed by thousands since it first reached the public eye in 2012: Fast Healthcare Interoperability Resources (FHIR). To health care reformers, FHIR embodies all the values and technical approaches they have found missing in health care for years. And the development process for FHIR is as unusual in health care as the role the standard is hoped to play.
Reform From an Unusual Corner
FHIR started not as an industry initiative but as a pet project of Australian Grahame Grieve and a few developers gathered around him. From this unusual genesis it got taken up by HL7 and an initial draft was released in March 2012. Everybody in health care reform rallied around FHIR, recognizing it as a viable solution to the long-stated need for application programming interfaces (APIs). The magic of APIs, in turn, is their potential to make data exchange easy and create a platform for innovative health care applications that need access to patient data.
So, as a solution to the interoperability problems for which EHR vendors had been dunned by users and the US government, FHIR won immediate accolades. But these vendors knew they couldn’t trust normal software adoption processes to use FHIR interoperably–those processes had already failed on earlier standards.
HL7 version 2 had duly undergone a long approval process and had been implemented as an output document format by numerous EHR vendors, who would show off their work annually at an Interoperability Showcase in a central hall of the HIMSS conference. Yet all that time, out in the field, innumerable problems were reported. These failures are not just technical glitches, but contribute to serious setbacks in health care reform. For instance, complaints from Accountable Care Organizations are perennial.
Congress’s recent MACRA bill, follow-up HHS regulations, and pronouncements from government leaders make it clear that hospitals and their suppliers won’t be off the hook till they solve this problem of data exchange, which was licked decades ago by most other industries. It was by dire necessity, therefore, that an impressive array of well-known EHR vendors announced the maverick Argonaut project in December 2014. (I don’t suppose its name bears any relation to the release a few months before of a highly-publicized report from a short-lived committee called JASON.)
Argonaut include major EHR vendors, health care providers such as Partners Healthcare, Mayo, Intermountain, and Beth Israel Deaconess, and other interested parties such as Surescripts, The Advisory Board, and Accenture. Government agencies, especially the ONC, and app developers have come on board as testers.
One of the leading Argonauts is Micky Tripathi, CEO of the Massachusetts eHealth Collaborative. Tripathi has been involved in health care reform and technical problems such as data exchange long before these achieved notable public attention with the 2009 HITECH act. I had a chance to talk to him this week about the Argonauts’ progress.
Reaching a Milestone
FHIR is large and far-reaching but deliberately open-ended. Many details are expected to vary from country to country and industry to industry, and thus are left up to extensions that various players will design later. It is precisely in the extensions that the risk lurks of reproducing the Tower of Babel that exists in other health care standards.
The reason the industry have good hopes for success this time is the unusual way in which the Argonaut project was limited in both time and scope. It was not supposed to cover the entire health field, as standards such as the International Classification of Diseases (ICD) try to do. It would instead harmonize the 90% of cases seen most often in the US. For instance, instead of specifying a standard of 10,000 codes, it might pick out the 500 that the doctor is most likely to see. Instead of covering all the ways to take a patient’s blood pressure (sitting, standing, etc.), it recommends a single way. And it sticks closely to clinical needs, although it may well be extended for other uses such as pharma or Precision Medicine.
Finally instead of staying around forever to keep chopping off more tasks to solve, the Argonaut project would go away when it was done. In fact, it was supposed to be completed one year ago. But FHIR has taken longer than expected to coalesce, and in the meantime, the Argonaut project has been recognized as a fertile organization by the vendors. So they have extended it to deal with some extra tasks, such as an implementation guide for provider directories, and testing sprints.
That’s some history; the next section of this article will talk about the fruits of the Argonaut project and their plans for the future.