Let’s Get Technical Group: April 17, 2020

Stephen Konya & Patrick Murta

Getting There FAST:

Barriers and Solutions for Adopting FHIR

In the NIC of Time…

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Agenda

Welcome, NIC Overview & New Participant Introductions

Today’s Webinar:

Topic: Getting There FAST: Barriers and Solutions for Adopting FHIR

Presenters:

Stephen Konya, Senior Innovation Strategist, Office of the National Coordinator for Health

IT (ONC)

Patrick Murta, Solution Architecture Fellow, Humana | FAST Initiative Chief Architect | Da

Vinci Operating Member

Agenda

Upcoming Webinars:

• 04/24: It’s a WIN: A New Data-Driven Approach for Measuring Well-being –

Somava Saha

• 05/01: Interoperability Insights - State Health IT Connect Summit/SOC Institute

Collaboration (Gravity, DaVinci, Carin Alliance, Project Unify)

• 05/08: Getting Evidence into Practice: Lessons from the Opioid Crisis – Elisabeth Kato,

Roland Gamache, and Suchitra Iyer - Agency for Healthcare Research and Quality (AHRQ)

What is the National Interoperability Collaborative (NIC)?

NIC is a “Community of Networks” designed to

increase collaboration within and across multiple

domains to improve health, safety, well-being and

operations.

We focus on Six Domains:

Human Services, Public Health, Education, Public Safety,

Emergency Medical Response, Health Care IT

"NIC is an idea whose time has come!"David Fukazawa, Managing Director of Kresge Foundation's Health Program

NIC is collaboratively developing a National

Action Agenda over the next nine months.

It will serve as a roadmap to guide the design, development and

implementation of system-level, cross-domain

interoperability to advance SDOH post COVID19.

hub.nic-us.org

Join the NIC Community

Getting There FAST: Barriers and Proposed Solutions for Scaling FHIR

Presenters

PATRICK MURTA

Chief Interoperability Architect & Fellow, Humana

Chief Architect, FHIR at Scale Taskforce (FAST)

STEPHEN KONYA

Senior Innovation Strategist, HHS/ONC

ONC Lead, FHIR at Scale Taskforce (FAST)

What type of organization do you represent?

• FAST Overview– What is FAST?– P2 FHIR to FAST– FAST Organization & Community Engagement– Collaborative Efforts

• Setting the Stage– API Overview– What is FHIR?– Why FHIR Adoption– Importance of Infrastructure

• FAST Progress & Proposed Solutions– Patient Journey– FAST Proposed Solutions– Identified Regulatory Barriers

• In Closing– FAST alignment with ONC Goals– Resources & How to Get Involved

Agenda

The FHIR at Scale Taskforce (FAST), convened by the Office of the National Coordinator for Health IT (ONC), brings together a highly representative group of motivated healthcare industry stakeholders and health information technology experts.

What is FAST?

The group is set to identify HL7® Fast Healthcare Interoperability Resources (FHIR®) scalability gaps and possible solutions, analysis that will address current barriers and will accelerate FHIR adoption at scale.

P2 FHIR to FAST

Ecosystem

Tiger Team

Identified &

Prioritized 21+

Use CasesQ2/Q3 2018

Executive

Steering

Committee

Formed & 1st

MeetingQ4 2018

Oct 2017 – Payer + Provider (P2) FHIR Taskforce EstablishedOriginally focused on Payer/Provider collaboration

Q1 2018 – Taskforce Charter CreatedProblem: Ecosystem and infrastructure barriers prevent wide-scale adoption and deployment of FHIRPurpose: Address ecosystem barriers and accelerate adoption of FHIR for production exchange of clinical information between payers and providersNeed: Establish a national architecture for standardized exchange of information using FHIRScope: Establish ONC taskforce that leverages “tiger teams” to focus on near term, practical approaches for the standardized exchange of information using FHIR

Initial Tiger

Team Calls

CommencedQ2/Q3 2018

P2 Becomes FAST

Jan 2019Same mission, new

name to better reflect

work FAST is doing

and broader

stakeholder

engagement

Technical &

Regulatory

Barriers v1

PublishedQ2 2019

14 Ecosystem

Use Cases v1

PublishedQ2 2019

Possible

Solutions to

Tech BarriersQ3 2019

Recommendations

for Regulatory

BarriersOngoing

1st FAST 101

Webinar

Sept 12th

10amET

1st TLC

Virtual Webinar

End of Sept

Companion

“Scalability”

Guides & PilotsTBD

TIGER TEAMS IDENTIFY:• Use Cases

• Technical/Regulatory Barriers

• Core Capabilities

• Gap Analysis

FAST Organization & Community Engagement

UPDATES

FEEDBACK

TECHNICAL LEARNING COMMUNITY (TLC)

EXECUTIVE STEERING COMMITTEE

(public-private mix)

COORDINATING COMMITTEE

(public-private mix)

SEVEN TIGER TEAMS

Ecosystem Use Cases

Identity

Security

Directory, Versioning and Scale

Exchange

Certification and Testing

Pilots

Information Sharing with TLC through:• Website• Periodic webinars• Newsletters• TLC Meetings• LinkedIn Group

Collaborative Efforts Towards FHIR Adoption

FHIR SOLUTIONS FOR VBC

SHARED Technical Challenges to

FHIR SCALABILITY Common Scalability Approaches

RAPID INDUSTRY ADOPTION OF FHIR-BASED SOLUTIONS

Patient & Provider Identity Management

Directory Services

Version Identification

Exchange Process/Metadata

Testing, Conformance & Certification

Security

INFRASTRUCTURE USE CASES

Payers/Providers

CORE DATA SERVICES

Provider/Provider

FHIR CONSUMER SOLUTIONS

Consumers

FUNCTIONAL USE CASES

OTHER COLLABORATIVE EFFORTS

NETWORK/CORE SERVICES

CONTRACTUAL ENFORCEMENT

CORE SERVICES

What is your familiarity with FHIR?

What is your organization’s status on FHIR?

FAST : Setting the Stage

API Overview

APIs…• An API is a software intermediary which

allows applications to talk to each other

• APIs allow the capabilities or data of one computer program to be used by another

• Lego blocks of data

• Doesn’t matter what the underlying computer or technology is

• APIs are a foundational technology that drives modern computing and the API economy (Amazon, Netflix, Google, Facebook, EBay, YouTube, Twitter, & etc.)

• APIs enable innovation in an unprecedented manner

• APIs are not new… simplified, easy to use versions of them are

APPTHEIR

APPAPI

REQUEST

DEVELOPERSwill access your assets through your API to build Mobile Apps and Web Apps based

on the data and software you share.

THE APIprovides universal access to whatever

assets you choose to share. Developers can "plug in" their apps and data.

ASSETSYour data and software

(and brand) become more valuable by being leveraged

by partners, developers, and third-party services.

END USERShave access to apps that

provide richer experiences by leveraging the data and

services of other apps.

WHAT IS FHIR?

*Representational State Transfer (REST) defines a set of constraints used for creating web services

FHIR® — Fast Healthcare Interoperability Resources

• An HL7 next generation standard

• Helps two computer systems talk to each other

FHIR "resources" are standardized & reusable

• Patient, practitioner, organization, deviceRequest

FHIR supports common exchange methods

• REST*, messaging, documents and services

FHIR supports the spectrum of integration

• Mobile phone apps, EHR-based data sharing,

institutional solutions

FHIR helps with existing use cases & provides for future

innovation

Referral/ Consult

Patient Medical Record

HealthcareDirectory

Provider

Payers

Services (eg, DME, Imaging)

PublicHealth

Research

Data available in-workflow supports value-based care and population health management

Why FHIR Adoption?

Comprehensive data integration

Promote progressive FHIR adoption

Reduce redundancy and duplication

Improve in-workflow data exchange to support value-based care and population health

CMS and ONC rules call for widespread APIs adoption using FHIR to enable consumers access to their health data

Drive innovation through data accessibility

Unlock new capabilities through API/ service methodologies

Improve consistency as an impetus for accelerating clinical data exchange

Reduce costs and time needed for infrastructure so it can be spent on patient care

Industry value levers for FHIR adoption:

Tying to Reality and Making Practical via CMS & ONC Rules

Mandating FHIR and consumer mediation as foundations of an integrated, competitive, and innovation friendly ecosystem.

/CMS/ONC proposes rules that align with market forces and reflect industry trends.

They provide yet another dimension to the interoperability inflection point we are in.

CMS Rule (CMS-9115-P)

• Patient access through standards based FHIR APIs

• Information exchange and care coordination across payers

• API based provider directories

• Care coordination through trusted exchange networks

ONC Rule (RIN 0955-AA01)

• Implements information blocking provision of Cures Act (and 7 exceptions)

• Standards based APIs

• Certification criteria

• Content specifications

Member Empowered

Standards Based

Open APIs

Care Coordination Across Payers and Providers

Innovation

Lack of Consistent Infrastructure Impacts Flow

Well-Planned Infrastructure Creates Efficiency

How familiar are you with the challenges of clinical

healthcare data exchange at scale?

FAST : Challenges and Proposed Solutions

Patient Journey - Today

Sophisticated technology exists but without consistent data integration, phone and fax are still the default

Patient Journey - Ideal

Real-time data exchange removes the need for phone calls and faxes, streamlining the entire interaction.

Patient Journey - Challenges

We want to identify and address the barriers for data exchange to happen consistently, for every transaction, specifically FHIR transactions

REQUESTING SYSTEM RECEIVING SYSTEM

Formulates FHIR

Request

Looks Up the FHIR Endpoint for Recipient

Example FHIR Transaction Journey

DIRECTORY

CHALLENGE: There are multiple places to find endpoints.Is there a place I can go to find all of them?

SOLUTION: Directory services approach for endpoint discovery

PCP needs information from Payer

Payer receives PCP request

PCP views patient information

Patient visits Primary Care Physician (PCP)

Formulates FHIR

Request

EXCHANGE

CHALLENGE: Enabling transaction exchange

SOLUTION: Exchange and meta data approach

DIRECTORY

Transaction Information (eg, Header)

Appropriately Configured

EXCHANGE

CHALLENGE: A way to measure conformance to the standard

SOLUTION: Conformance & certification approach

DIRECTORY

Receives Transaction,

Validates Requestor, Validates Version

CONFORMANCE & CERTIFICATION

Formulates FHIR

Request

REQUESTING SYSTEM

RECEIVING SYSTEM

VERSIONING

EXCHANGE

CHALLENGE: A way to communicate and manage multiple versions

SOLUTION: Versioning approach

DIRECTORY

Formulates FHIR

Request

REQUESTING SYSTEM

RECEIVING SYSTEM

DIRECTORY

EXCHANGE

VERSIONING

Performs Patient Matching and Sends

Back Not Found If Unable To Do So

IDENTITY

CHALLENGE: How can a requestor and receiver uniquely identify the patient/member?

SOLUTION: Identity matching approach

Formulates FHIR

Request

REQUESTING SYSTEM

RECEIVING SYSTEM

IDENTITY

SECURITY

DIRECTORY

EXCHANGE

VERSIONING

Authenticates FHIR User’s

Filters Out Data That Does Not

Have Consent

CHALLENGE: How can the industry ensure only “right to know” requestors access data and patient consent is followed?

SOLUTION: Security approach for authorization & authentication

Formulates FHIR

Request

REQUESTING SYSTEM

Requesting System Receives Data

Generates & Returns FHIR

Response

3 5a 5b 6

RECEIVING SYSTEM

IDENTITY

SECURITY

PILOTS

DIRECTORY VERSIONINGEXCHANGE

DIRECTORY

EXCHANGE

VERSIONING

Formulates FHIR

Request

Authenticates FHIR User’s

Filters Out Data That Does Not

Have Consent

Directory Services Identity Security

Testing, Conformance, & Certification Versioning Scaling

Known Technical Barriers

RecommendedInfrastructure Solutions

FAST Solutions

FAST Solution Input• Tiger Teams• TLC• SME

ProposedInfrastructure Solutions

Tiger Teams

Standards Process Regulation

Evaluation, Feedback, and Pilots

Ecosystem Use Case

Identity

Directory, Version & Scale

Testing & Certification

Exchange Process

Security Pilots

Ecosystem Use Cases

Core Capabilities

Technical Barriers

Operationalize Solutions

FHIR Adoption - Technical Challenges & FAST Proposed Solutions

ProposedInfrastructure Solutions

CHALLENGE: How do we enable consistent and reliable transaction exchange?

PROPOSED SOLUTIONS: - Reliable Routing with Metadata Across Intermediaries- Reliable Routing Across Intermediaries Using Destination Specific Endpoints

CHALLENGE: A way to measure conformance to the standard

PROPOSED SOLUTION: ONC FHIR Testing and Certification Program

CHALLENGE: How do we manage permissions & security across millions of patients/payers/providers?

PROPOSED SOLUTIONS: - Trusted Dynamic Client Registration- Tiered OAuth- UDAP Authentication & Authorization

DIRECTORYCHALLENGE: There are multiple places to find endpoints.Is there a place I can go to find all of them?

PROPOSED SOLUTION: A national solution for FHIR Endpoint Discovery

CHALLENGE: How can a requestor and receiver uniquely identify the patient/member?

PROPOSED SOLUTIONS: - Mediated Patient Matching- Collaborative Patient Matching- Distributed Identity Management

DIRECTORY, VERSIONS AND SCALE

IDENTITY

EXCHANGE PROCESS

TESTING & CERTIFICATION

SECURITY

VERSIONSCHALLENGE: A way to communicate and manage multiple versions

PROPOSED SOLUTION: Supporting multiple production versions of FHIR

SCALECHALLENGE: How can a high volume of FHIR transactions be consistently and predictably exchanged in a hybrid exchange model?

PROPOSED SOLUTION: Requirements for FHIR RESTful exchange intermediaries

FAST Vision of The Future

A National Solution for FHIR Endpoint DiscoveryThe model incudes an API-enabled national source for validated directory information available to any local directory or workflow. The directory contains entity and individual information to determine endpoint relationships. Also, endpoint information will include supported IG’s, trust frameworks, meta data requirements, etc.

Supporting Multiple Production Versions of FHIRMoving forward, most resources, extensions, & profiles will be normative. The FHIR version supported by a partner will be available as part of directory services endpoint discovery and as part of the FHIR servers' conformance statement. In addition, all FHIR artifacts provide version number as part of the exchange. New versions will be backwards compatible for normative content.

Requirements for FHIR RESTful Exchange IntermediariesThe ecosystem will support a mixed model (point to point, gateways, and intermediary). Performance and availability requirements will need to be established and all other dimensions of FAST will need to operate as planned.

Reliable Routing with Metadata Across Intermediaries Reliable Routing Across Intermediaries Using Destination SpecificGiven that the future includes both point to point, gateway, and intermediaries, the model ensures reliable routing across one or many hops since the FHIR artifact carries its routing identifiers.

Mediated Patient MatchingCollaborative Patient MatchingDistributed Identity ManagementThe FAST proposals for identity include models to reliably match patients in real-time using contemporary technologies including FHIR. Proposed solutions including near real-time patient matching using FHIR match operations (mediated patient matching), collaborative patient matching in which patient identifier is assigned and participants agree on usage and cross-walks models, and a network of trusted identity matching services (patient matching with FHIR match and local and global identifiers with future support for patient and payer).

Trusted Dynamic Client RegistrationAuthentication & AuthorizationAgile, reliable, secure access is foundational to the ecosystem of the future. The FAST model supports the ability for dynamic yet trustworthy access to data. A trusted ecosystem enabled by proposed solutions including dynamic client registration and client token request and JWT based client authorization and authentication.

ONC FHIR Testing and CertificationThe model includes a proposal for testing platform and a certification authority to validate base FHIR conformance & FAST criteria conformance.

A National Solution for FHIR Endpoint DiscoveryThe model incudes an API-enabled national source for validated directory information available to any local directory or workflow. The directory contains entity and individual information to determine endpoint relationships. Also, endpoint information will include supported IG’s, trust frameworks, meta data requirements, etc.

Supporting Multiple Production Versions of FHIRMoving forward, most resources, extensions, & profiles will be normative. The FHIR version supported by a partner will be available as part of directory services endpoint discovery and as part of the FHIR servers' conformance statement. In addition, all FHIR artifacts provide version number as part of the exchange. New versions will be backwards compatible for normative content.

Requirements for FHIR RESTful Exchange IntermediariesThe ecosystem will support a mixed model (point to point, gateways, and intermediary). Performance and availability requirements will need to be established and all other dimensions of FAST will need to operate as planned.

Reliable Routing with Metadata Across Intermediaries Reliable Routing Across Intermediaries Using Destination SpecificGiven that the future includes both point to point, gateway, and intermediaries, the model ensures reliable routing across one or many hops since the FHIR artifact carries its routing identifiers.

Mediated Patient Matching | Collaborative Patient Matching | Distributed Identity ManagementThe FAST proposals for identity include models to reliably match patients in real-time using contemporary technologies including FHIR. Proposed solutions including near real-time patient matching using FHIR match operations (mediated patient matching), collaborative patient matching in which patient identifier is assigned and participants agree on usage and cross-walks models, and a network of trusted identity matching services (patient matching with FHIR match and local and global identifiers with future support for patient and payer).

ONC FHIR Testing and CertificationThe model includes a proposal for testing platform and a certification authority to validate base FHIR conformance & FAST criteria conformance.

Trusted Dynamic Client Registration | Authentication & AuthorizationAgile, reliable, secure access is foundational to the ecosystem of the future. The FAST model supports the ability for dynamic yet trustworthy access to data. A trusted ecosystem enabled by proposed solutions including dynamic client registration and client token request and JWT based client authorization and authentication.

Potential Regulatory Barriers

Patient Identifier

Data Blocking

HIPAA Minimum Necessary

Regulatory Mandate for a Single Named Standard

HIPAA Transactions Requiring X12

Use of NPPES as the Repository for Endpoints

Do these barriers and the evolving solutions seem on track?

In Closing

1) ONC is focused on connecting healthcare and health data through a national interoperable Health IT infrastructure.

2) ONC is working to reduce the regulatory and administrative burden related to the use of health IT, including EHRs.

3) ONC is working on ways to give clinicians more time to focus on what matters – caring for their patients.

FAST Supports Overarching ONC Goals

Supporting Documents;

• ONC's Cures Act Final Rule

• Strategy on Reducing Burden Relating to the Use of Health IT and EHRs

• 2020-2025 Federal Health IT Strategic Plan

(deadline for public comment extended to 4.3.20 at 11:59:59 PM ET!)

Putting the patient first in health technology enables the health care system to deliver:• Transparency into the cost and outcomes of their care

• Competitive options in getting medical care

• Modern smartphone apps to provide them convenient access to their records

• An app economy that provides patients, physicians, hospitals, payers, and employers with innovation and choice

ONC's 21st Century Cures Act Final Rule

Direct Links;• Fact Sheets• Webinars• Media/Press• Blog Post• Download Final Rule

Main Landing Page;https://www.healthit.gov/curesrule/

FAST Initiative Output & Communication Strategy Update

All content is available on the https://tinyurl.com/ONC-FAST

FAST CONTENT FAST COMMUNICATION STRATEGY

FAST Initiative Use Cases, Version 2

FAST Initiative Core

Capabilities

FAST Regulatory and Policy Barriers,

Version 1

FAST Technical Barriers, Version 1

FAST Solutions (In Development/

Drafts)

FAST 101 and Keystone

Presentations

FAST 101 - Public Webinar

Technical Learning Community

2019 FAST End of Year

Report

Industry Speaking Engagements

Published Content and FAST Artifacts

All content is available on the https://tinyurl.com/ONC-FAST SK

FAST 2019 End of Year Report

2019 End of Year Report

Summarizes progress made in 2019 and provides a sneak-peak of work in 2020

Patient & Provider Identity Management

Directory Services

Version Identification

Exchange Process/Metadata

Testing, Conformance & Certification

Security

Pilots

FAST Focus

Join the Technical Learning Community to get updates and provide input on the technical and regulatory barriers, use

cases, and proposed solutions as they are developed.

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WANT TO GET INVOLVED??

Questions?

Thank You – Today's Presenters

Patrick MurtaFAST Chief Architect

pmurta@humana.com

Stephen KonyaONC – FAST LeadStephen.Konya@hhs.gov

For more information on the FAST Initiative, visit the FAST Project Page

Have any further questions/suggestions?

Please contact Stephen Konya at Stephen.Konya@hhs.gov& Diana Ciricean at Diana.Ciricean@hhs.gov

Upcoming Webinar: It’s a WIN: A New, Data-Driven Approach for Measuring Well-Being

April 24 | 12:00pm-1:30 pm ET

How might a loss of jobs in the transportation sector affect deaths of despair, such as those caused by alcohol, drugs or suicide? How might broadband access affect people’s movement from rural to urban areas? Insights into questions such as these are being provided for the first time by the Well-being in the Nation (WIN) measures, which examine how data across sectors might influence population and community health. This webinar/discussion will focus on the process of developing the measures, review the first multi-sector findings regarding community well-being, and share insights relating to their application.

hub.nic-us.org/events/it-s-a-win-a-new-data-driven-approach-for-measuring-well-being

Somava Saha

Upcoming Webinar: From Indiana to the National Accelerators:

COVID-19 and Interoperability for a Better Path Forward

May 1st| 12:00pm-2:00 pm ET

hub.nic-us.org/events/from-indiana-to-the-national-accelerators-covid-19-and-interopera

Upcoming Webinar: Getting Evidence into Practice: Lessons from the Opioid Crisis

May 8 | 12:00pm-1:30 pm ET

Join experts from the Agency for Healthcare Research and Quality (AHRQ), to learn about resources for using evidence to combat the opioid crisis; about evidence syntheses on what works to manage pain and Opioid Use Disorder (OUD); and about tools to integrate the latest guidelines at the point of care.

hub.nic-us.org/events/getting-evidence-into-practice-lessons-from-the-opioid-crisis

Upcoming Webinars

04/24: It’s a WIN: A New Data-Driven Approach for Measuring Well-being –

Somava Saha

05/01: Interoperability Insights - State Health IT Connect Summit/SOC Institute

Collaboration (Gravity, DaVinci, Carin Alliance, Project Unify)

05/08: Getting Evidence into Practice: Lessons from the Opioid Crisis – Elisabeth

Kato, Roland Gamache, and Suchitra Iyer - Agency for Healthcare Research and Quality

(AHRQ)

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Let’s Get Technical Group: April 17, 2020

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