How the FHIR Community of Practice Empowers VA Transitions of Care
By Jay Lyle, Ph.D., FHL7
Background
HL7 FHIR® is an international industry data standard for the exchange of healthcare data. The development of FHIR was highly beneficial because it supports the seamless integration of separate electronic health systems. However, seamless integration is not an “out-of-the-box” feature inherent to FHIR. Significant effort must still be expended to solve clinical, logical, and organizational riddles. FHIR’s lightweight REST paradigm contributed to an impression that implementation of the data exchange standard would be easy. This led to a “very high peak of expectations” of results followed by a broad “trough of disillusionment.”
As health information is increasingly captured digitally, it becomes more important for organizations to be able to send and receive information related to a patient encounter and their medications automatically. Doctors may need notes from an ER visit. One specialist may need to consult with another specialist. Pharmacists may need to consolidate medication records from different providers. Insurance companies may need more detail about a claim. Any needed information in a healthcare setting could conceivably come from another organization. Providers and supporting staff need a shared agreement for the formats of the data in the exchanged messages to do their jobs effectively.
The VA is working hard to ensure that Veterans are able to get access to care anywhere, not just at VA facilities. Coordinating care across these facilities requires the electronic exchange of information, and the automated exchange of information requires a common implementation guide to be used as a reference by all of the providers.
The difficulty in implementing the FHIR standard in software is compounded by clinical data complexity, which is ever evolving in an enterprise as large as the VA. Ambiguity arises because there are multiple ways to represent data in FHIR messages sent between providers. The precise meaning of clinical data can be unclear when the receiving party tries to interpret it. Their EHR system might use a different reference vocabulary. Resolving the ambiguities necessitates ongoing detailed discussions across multiple groups of stakeholders at the various provider organizations. If ambiguities are not resolved, they may present risk to patient safety.
Current Project Work
J P Systems is currently managing the VA FHIR Community of Practice (CoP) which supports VA FHIR software developers. The CoP is an effort specifically designed to convene people from across VA to nurture consensus and establish governance over how exactly Veteran data is represented in FHIR standards. This CoP group not only identifies requirements for putting Veteran data into FHIR message payloads, but the CoP facilitates agreement across multiple teams and publishes the consensus in a FHIR Implementation Guide (IG).
The CoP project’s mission is to ensure consistency. Dozens of projects pull data out of VistA for clinicians, patients, and payers. This consistent approach is crucial for aligning VA data with external standards, like U.S. FHIR Core, and meeting constraints, like the need to align with Oracle Health. The team gathers consensus across diverse project teams and publishes it in a FHIR Implementation Guide (IG). The IG ensures guidelines reach all teams, including those who could not be at the table for discussion. This work supports dozens of project teams and involves thousands of data elements and term maps. Consensus is critical for clarity of codes. We are pleased to report that the CoP project effort is going strong after four successful years of collaboration.
Next Steps for Interoperability
The most obvious result of data standardization is better transitions of care, such as when a Veteran sees a non-VA specialist. But standardization, and the predictable, reliable, and precise data they enable, also empowers clinical decision support tools. These tools require quality in the data inputs they use to help make recommendations and support administrative and financial processes. Those inputs help Veterans get the care they need when and where they need it. In addition, standardization is critical to the conduct, exchange, and verification of clinical research. Research heavily depends on the clarity of data used to draw conclusions.
As it becomes possible to more easily exchange patient records, two other factors come into view. First, clinical data quality becomes critical. Exchanging data is an expensive and pointless exercise if the recipient can’t trust it. Like other computable processes, quality assessment tools depend on well defined inputs to support data evaluations.
Second, in the future AI agents will consume more of this data. While these AI agents are ingenious, the goal is controlled, quality results not the quantity of results. It is critical to ensure that the framework provides unambiguous content. Data standards like FHIR can do that, but not automatically. AI agents require governance, and the standards-based context that enables that governance also requires an ongoing effort.
With these carefully curated data standards in place, when a Veteran returns from a specialist visit, currently a care summary can follow them back to their primary care provider (PCP) via Direct Secure Email. As a result, PCPs are accurately informed about the specialist visit. If the specialist’s system used a clinical decision support rule to draw a conclusion, the PCP can access and review the rule. If the PCP’s system uses an agent to propose next steps, the PCP can view and, if necessary, correct the agent’s assumptions. All of these entities – providers and systems – are using shared standards for communication at every layer, from the voltage of the wires to the clinical vocabularies in the reports.
Conclusion
FHIR’s potential to transform the provision of healthcare is immense. Its realization depends on solving complex riddles inherent in standardizing data. The VA FHIR CoP provides exactly the right forum for establishing consensus. It defines requirements for Veteran data standards and turns potentially seamless integration into a practical, realized reality of interoperability. The Implementation Guide published agreed guidelines. The CoP ensures consistency across VistA driven projects. Teams leveraging VistA data can use the FHIR Implementation Guide to ensure standardized and accurate data representation for Veterans.
Jay Lyle is Chief Standards Officer for J P Systems, Inc. He serves as a consultant to the Veterans Health Administration’s Digital Health Office for standards implementation. His recent work includes providing guidance for exchanging VA data in FHIR, conducting the C-CDA-to-FHIR mapping project, and supporting the establishment of a SNOMED CT extension to support the LOINC Document Ontology.
After teaching composition and literature, he worked in systems integration as a business architect and project manager before focusing his efforts on data standards, which he has been designing and helping to implement for over ten years. Jay serves as Co-Chair of the Patient Care work group for the Health Level 7 (HL7) International standards development organization, where he is a Fellow. He holds a Ph.D. in Renaissance literature from the University of Virginia and an MBA from the Emory Goizeuta school of business.