· Nov 8, 2023

[Water Cooler Talk] FHIR, the holy grail of interoperability and EHR, or just another brick in the wall?

Hi everyone!

The other day I was reflecting on the possibilities that FHIR brings us in the world of interoperability and electronic medical records and it gave me mixed feelings, let me explain, first a small introduction.


As you well know, FHIR is based on parameterizing a series of concepts that it calls resources in JSON or XML format with the intention of covering the most common cases within the healthcare environment, relying on HTTP communications to cover CRUD and query functionalities.

Through this FHIR architecture, it is possible to develop a common base for the exchange of information on medical records and events (as HL7 did).

Spanish healthcare system

Let me briefly explain how the Spanish health system works.

The Spanish health system is a mixed system in which the State offers universal and "free" medical care that is complemented by private health insurance that offers certain services in its own hospitals or in concert with private hospitals. Each autonomous region into which the public administration is divided manages its own health system, thus having 17 public health systems, within which hospitals always have a certain degree of autonomy.

This means that the information systems used by each region are totally different from those used by the others and even between public hospitals in the same region.

Historia del Sistema Sanitario Español | Salud, Nutrición Y Deporte

What advantages would the use of FHIR provide in Spain

  • In a system like the Spanish one, the main advantage is being able to provide a unified clinical history format that can be interoperable between regions and hospitals with the improvements in medical care that this would produce.
  • It provides the tools to unify concepts and terminologies that would simplify any future development and reduce costs.

What problems exist when using FHIR in Spain

  • The decentralization of public administration in Spain makes it very difficult to reach an agreement between all regions to adopt a certain solution. This may cause some regions to opt for FHIR as a response while others opt for other solutions such as OpenEHR.
  • The presence of "legacy software" is very important, systems such as HIS, RIS and LIS have an average age of 12 and 15 years (more or less), the cost of adapting all these systems is very high and hardly justifiable as it is not an "emergency".
  • The implementation of FHIR servers is not simple and the exploitation of their data outside of the resource and bundle concepts is quite complex (bless IRIS FHIR SQL Builder!).
  • FHIR has not discovered fire, there are already many technologies that provide similar functionalities (OpenEHR, CDA...). It is not a new and revolutionary paradigm.

My personal conclusion

In my personal opinion FHIR is a fantastic technological solution for the interoperability of electronic medical records that would allow a substantial improvement in medical care but...

Its implementation in a system like the Spanish one practically depends on a political decision made by the central State, since if FHIR were implemented in a few autonomous regions it would only be another technology that would increase the complexity of the information systems and would not allow exploiting the advantages it provides, it would be like an HL7 v.3, very nice at first but then a burden that the organizations that adopted it must live with.

Something makes me think that despite how useful and practical it is, its implementation will be partial and it will remain as another "could have been" until a new technology or implementation emerges that is the solution to all our problems and we start again and again.

FHIR, the holy grail of interoperability and EHR, or just another brick in the wall?
Discussion (15)5
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xkcd: Standards

FHIR is only a part of the journey, the most important is that so many competing software are already on the market. The issue appears in cases when some applications could get updates and support for anything new, some not. Still, both of them would be required to communicate with each other and it will keep using some way or another some old standards anyway.

FHIR Resources (upper case when referring to the specification) represent a flexible healthcare data model that can be applied to many different use cases when that data model is constrained by creating FHIR Profiles.  The interoperability is in the constrained FHIR Profiles, not in FHIR Resources.  It is true that the base FHIR standard is equivalent to HL7 v2.  The HL7 v2 is syntactic interoperability only, as is the base FHIR standard, and you cannot apply a "profile" to HL7 v2.  It is not possible. 

Semantic Interoperabillity is hard and it exists only if there is a shared semantic model = FHIR Profile used by the systems exchanging data.  The same profile, because it is possible to create different profiles for a use case that are reasonable models but are not the same. 

FHIR is neither the holy grail nor just another technology.  It does offer the potential to enable semantic interoperability.  And FHIR was created by the same people, the same organization that created HL7 V3.  Lessons learned in the failed HL7 V3 were part of what guided the development of FHIR. 

I'd say in general, having a structured data with the actual names of fields is much better than "parsing" the text with delimiters. So I would vote for FHIR. Maybe at some point there will be a better way to represent data - and it is OK - and people will switch to it. The main idea - not to make it painful on the developers to rewrite everything!

We can see here the differences between R4 and R5 releases of FHIR. I can't imagine an organization migrating FHIR respositories every 3 or 4 years to keep updated to the latest version. What I forsee it's a future with a lot of organizations using different versions of FHIR and trying to communicate among them struggling against the differences...exactly the same that we have right now.

What matters is more the maturity of each resource.
Maturity is rated from 0 to 5, where 0 is a draft, and 5 is normative.
Further the realse of FHIR, more mature resources are.
It's plan than R6 will be the first normative release of FHIR, it's even plan to be an ISO standard.
This mean that all resources related to Patient will be normative, and will not change in the future.