Uncertain Health in an Insecure World – 67

“Golden Fleece”

In Greek mythology, soon after his birth, Jason’s life was under threat. His mother Alcimede smuggled him to Mount Pelion, where he was raised by the centaur, Chiron, a trainer of heroes. Once grown, a band of 85 men, the Argonauts, accompanied Jason on his quest to steal the Golden Fleece. Their ship, the Argo, sailed to Colchis where the Golden Fleece (below) was guarded by a dragon. The goddess Hera protected Jason and the Argonauts during their long & perilous journey. In the end, Jason was successful; he returned to Thessaly to ascend the throne of Iolcus.

As in ancient Greece, in modern times, seeking the Golden Fleece is a long & perilous journey.

With increasing digitization of the healthcare ecosystem, electronic health records (EHR) must become mobile to follow the flow of patient care. But healthcare has lagged behind other industries in the use of web technologies. Rob Brull of Carepoint Health in Dallas notes that, “Healthcare has relied on integrating the healthcare enterprise (IHE) and simple object access protocol (SOAP) for (data) transport, which can be cumbersome.” After 20 long years and several versions, Health Level 7 (HL7; below) emerged as the healthcare data exchange and information content modeling standard.

Now, having reached its destination, HL7 remains landlocked. What’s next?

Fast Healthcare Interoperability Resources (FIHR, pronounced “fire”) are new specifications and standards for electronically exchanging healthcare information, based on web industry approaches. This data exchange architecture, spearheaded by Australian software developer Graham Grieve (below) in 2013, is intended to reduce healthcare information technology (HIT) bottlenecks and to offer more granular data access – to achieve true HIT interoperability. Eventually, FHIR will support automated clinical decision-making and other machine-based structured data processing.

FHIR is mapping the uncharted waters of HIT mobility.

FHIR has developed built-in mechanisms for traceability to the HL7 Reference Information Model (RIM), and to other content models. RIM is a large pictorial representation of HL7 (Version 3) clinical data domains that identifies the life cycle of a message or of message groupings. Brull adds, “FHIR uses Representational State Transfer (REST) web API’s. It is more lightweight.” 

REST-ful or not, just what are API’s?

Virtually all software has to request other software to do something for it. Application program interfaces (API’s) are a set of routines, protocols and tools for building software applications. API’s specify how software components should interact, and are used when programming graphical user interface (GUI) components. An ‘asking’ software program uses a standardized set of API requests that have been pre-defined for the ‘answering’ program. In this way, an API grants access to or opens another application (below).

Josh Walker of the Forrester Research Inc. in Cambridge Massachusetts says that, today, building an application without API’s is “basically like building a house with no doors… (API ) is how you open the blinds and the doors and exchange information” through them.

HIT typically confuses the system of record (which is stable and massive) from the systems of consumption (which are more malleable and smaller). According to former Obama Administration Chief Technology Officer, Aneesh Chopra (above), the processing of these differing types of information requires a lot of “handshakes and handoffs”. Back in olden times (2010), the U.S. government had no solutions for people shopping for healthcare plans. Aneesh recalls that he turned to the private sector to avert a failed launch of Obamacare’s Healthcare.gov 1.0 website, hiring Ed Mullen (below), a user interface (UI) web design guru from New Jersey, to come to the rescue.

API’s are featured in the Accountable Care Act (i.e., Obamacare) 2015 final rule on healthcare exchange standards for employers, in order to assure that patients have the right to access their personal health information (PHI) and to connect to their PHI using an app of their choice from an app gallery. The U.S. government’s April letter to insurers in the federally-facilitated marketplace (FFM) sets forth a requirement to have a website with an API connection to the FFM, as an alternative to patient portals. This connection flexibly opens up the electronic healthcare system for individuals using mobile devices, or by those using machines with patient permission.

Such specifications are consistent with Obamacare’s stage-3 EHR healthcare system adoption and certification criteria.

These days, innovative start-ups like Stride Health use the government's own data to help employees search for the most cost-effective healthcare insurance plan, one that fits them, in five minutes or less!  Instead of saying to employees, “Here’s the URL to Healthcare.gov… Atta-boy,” ever-entrepreneurial Uber has partnered with Stride Health to help their drivers choose the best healthcare plans, and save them money (below).

JASON is an independent group of scientists and Nobel laureates, thought leaders who advise the U.S. government on science and technology. One of JASON’s goals is to promote public policies that create an open, interoperable health data infrastructure. JASON’s roots in the Viet Nam War and nuclear proliferation eras once created a close linkage to DARPA. But in its recent 2013-14 reports, JASON decries the lack of EHR interoperability in the current HIT ecosystem, and advocates for policy changes to adopt a new architecture in the U.S. and international EHR meaningful use requirements for healthcare systems.

Enter the modern day heroes…

The Argonaut Project is a private sector initiative intended to rapidly advance industry-wide adoption of modern open interoperability standards. This market-driven core and documentation project is sponsored by modern HIT Argonauts – healthcare insurers, EHR vendors, healthcare systems, major consulting firms and pharmacy distributors. Their quest is to rapidly develop a first-generation FHIR-based API and core data services specification that will enable expanded healthcare information sharing for EHR’s and other HIT’s, based on Internet security standards and architectural patterns & styles.

How will Google or Apple get involved in the guidance of care in chronic diseases, where disease complexity & diversity makes the chances of precision medicine accuracy low?

The combination of FHIR for simple content summaries (encoded using extensible markup language, XML) and REST standards for data transport would bring HIT into alignment with more modern web services approaches used by companies such as Facebook, Yahoo and Google. In the end, as noted by Arien Malec at McKesson’s RelayHealth, “to expose a medication list to authorized parties, the current systems are not designed to do that, and it takes a lot of extra work.” Malec’s good use case example would be to offer mobile app developers access to patient data. “If you are going to do that using FHIR it’s going to be cheaper, faster and better that rolling your own.”

The Substitute Medical Applications Reusable Technologies (SMART) collaboration between Harvard and the U.S. Office of the National Coordinator (ONC) for HIT is actively creating an API for substitutable health apps that can run across multiple EHR’s. ‘SMART-on-FHIR’ is a prototype developed to support FHIR’s potential for providing a robust open-architecture health API.

Like ancient explorers, “information altruists” are more likely to openly share their PHI. But if this increases the cost of an insured pool of employees for an employer, it could cost these adventuresome adopters their jobs.

A recent Kaiser-Permanente member survey revealed that 60% would give up some health information privacy if it improved their healthcare. In Amy Edgar’s Robert Wood Johnson Foundation sponsored @FlipTheClinic project, the July 2015 ‘Flip 55’ showed that 16 consecutive patients answered that they did want their hospital EHR discharge summaries sent to them, while 2/3rds of stage-1 EHR adopters stated that nobody asked for or wanted their discharge summaries.

Another disruptive technology disconnect!

“Digital Health Advisors” will soon function (via API’s) as trusted navigators to the right healthcare in the right setting at the right time.

Mapping a myth is complicated.

While Greek history scholars agree on the Argonauts' route from Greece to Colchis (green), their return route (orange) has been the subject of a bewildering array of interpretations… of geography... of lost languages… all clouded by fear and ignorance.

We in the Square have long followed the mythic journey of interoperable health information technology. We’ll worry about the route back after we’re there. 

The Golden Fleece is finally within reach… Beware the dragon!