[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.

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.

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.