FHIR® - Fast Healthcare Interoperability Resources®
Fast Healthcare Interoperability Resources (FHIR) is a Health Level Seven International® (HL7®) standard for exchanging health care information electronically. The health care community is adopting this next generation exchange framework to advance interoperability. Electronic health records (EHRs) represent patient data in different ways (e.g., medications, encounters) and FHIR provides a means for representing and sharing information among clinicians and organizations in a standard way regardless of the ways local EHRs represent or store the data. FHIR combines the best features of previous standards into a common specification, while being flexible enough to meet the needs of a wide variety of use cases within the health care ecosystem. FHIR focuses on implementation and uses the latest web technologies to aid rapid adoption.
FHIR Quality Measurement
The health care community and CMS are exploring a potential transition to FHIR-based quality measurement beginning with research and testing. Currently used quality standards, Quality Data Model (QDM), Clinical Quality Language (CQL), Health Quality Measure Format (HQMF), and Quality Reporting Document Architecture (QRDA), remain the backbone of electronic clinical quality measure (eCQM) development and reporting. However, the FHIR standard has potential to better align with the EHR's ability to share data in clinical settings, to improve alignment with clinical decision support initiatives, and to reduce overall burden on measure developers and implementers.
In order to assess the transition to FHIR quality measurement, it is important to understand the components of an eCQM and how the components will evolve with FHIR. As shown in the graphic, an eCQM is composed of three primary parts, the data model, expression logic, and structure.
- Data Model: How to describe the patient’s medical record data needed to calculate the measure
- Expression Logic: How to calculate the result and evaluate the performance
- Structure: The container and sections describing measure metadata, numerator, denominator, exclusions, exceptions
The left side of the graphic shows the current state and the right side of the graphic shows the potential future state if CMS adopts FHIR for eCQMs.
A FHIR eCQM uses the FHIR Quality Measure Implementation Guide and the Data Exchange for Quality Measures (DEQM) Implementation Guide. The goal is to align quality measurement standards for eCQM development and reporting:
- Quality Improvement Core Framework (QI-Core) replaces QDM for clinical data. QI-Core is a version-specific data model built directly on top of FHIR resources (US Core and base FHIR resources).
- FHIR Quality Measure replaces HQMF for eCQM structure. The Quality Measure IG provides guidance in using the FHIR Measure resource for eCQM structure.
- DEQM individual and summary reporting replace QRDA I and QRDA III reporting.
FHIR
FHIR is composed of foundational, infrastructure, administrative, data exchange, and clinical reasoning capabilities. The Clinical Reasoning Module includes a collection of resources, extensions, and profiles to use the clinical knowledge artifacts such as clinical decision support rules, clinical quality measurement and reporting, order sets, and other capabilities to reason about the health care process prospectively and retrospectively. This module enables use of the same requests for information to improve care at the time of service (clinical decision support) and to evaluate care after it occurs (quality measurement), a vast improvement over previous care improvement standards.
FHIR Resources
Resources are the basis for all exchangeable FHIR content. Each resource includes a standard definition and human-readable descriptions about how to use the resource. Each resource also has a set of common and resource-specific metadata (attributes) to allow its use clearly and unambiguously. FHIR Resources can store and/or exchange many types of clinical and administrative data, which is the foundation for the data model used in quality measurement.
FHIR Profiles and Implementation Guides
A profile is a FHIR Resource that has been changed to meet the needs of a specific use case. For example, a measure developer may use the FHIR Observation resource to indicate anything observed about a patient. To indicate vital signs, there is a requirement for a vital signs profile, which provides greater structure by listing specific data (e.g., blood pressure, respiratory rate) along with appropriate coding for the specific data element(s). Using the vital signs profile in EHRs avoids variation and makes data sharing easier.
The FHIR community often assembles multiple easily consumable profiles into implementation guides (IGs). As an example, QI-Core is an IG containing profiles for representing the clinical data in an eCQM.
Exchange Specifications
The exchange specification defines how to exchange and manage resources in the form of real-time Representational State Transfer (RESTful) application programming interfaces (APIs) and messaging and documents. RESTful APIs allow for the exchange of FHIR resources using HTTP requests. The exchange specifications provide the foundation for reporting of eCQMs using FHIR.
Implementation Guides for Quality Measurement
For the purposes of investigating a transition to FHIR-based quality measurement, CMS is collaborating with HL7 to advance emerging standards and develop additional FHIR profiles for both eCQM development and reporting.
Data Model | Quality Measures | Measure Reporting | |
---|---|---|---|
Base Resource | US Core* | Measure Resource | Measure Report |
Implementation Guide | QI-Core | FHIR Quality Measure Implementation Guide | DEQM |
*US Core is an implementation guide representing FHIR for the US Realm
Benefits of FHIR
- Provides faster, real-time access to quality data
- Reduces burden for reporting quality measures
- Aligns CMS eCQM reporting with industry clinical data exchange framework, reducing implementation burden
- Enables automated data retrieval from EHRs and submissions of quality data through use of standards-based APIs
- Promotes interoperability
- Aligns data exchange requirements for quality measurement and reporting with interoperability standards used in other health care exchange methods
- Allows for additional quality data exchange methods
- Reduces effort to implement new measures
- Simplifies data mapping to a single FHIR mapping vs. mapping to HQMF and QRDA
- Improves alignment between eCQMs and clinical decision support
- Both use a common FHIR data model (FHIR QI-Core)
Disclaimer
FHIR® is the registered trademark of HL7 and is used with the permission of HL7. Use of the FHIR trademark does not constitute endorsement of the contents of this repository by HL7, nor affirmation this data is conformant to the various applicable standards.
General Resources
Health Level Seven International® (HL7®) has many Fast Healthcare Interoperability Resources (FHIR) resources on the HL7 website including a FHIR overview.
The Office of the National Coordinator for Health IT (ONC) has created several FHIR Fact Sheets.
- What is HL7 FHIR?
- Introduction to FHIR Resources
- FHIR Version History and Maturity
- The FHIR Application Programming Interface (API)
eCQM Related Tools for Use and Evaluation
- Bonnie: Bonnie was sunsetted June 28, 2024. Measure developers are to use the Measure Authoring Development Integrated Environment (MADiE).
- CQL-to-ELM Translator: A tool for producing an Expression Logical Model (ELM) file format from Clinical Quality Language (CQL).
- Clinical Quality Framework (CQF) Ruler: An implementation of FHIR's Clinical Reasoning Module for processing quality measures and serves as a knowledge artifact repository and clinical decision support service.
- CQL Evaluation Engine: An open source Java-based evaluation engine capable of evaluating the result of any CQL expression.
- CQL Execution Framework: A set of CoffeeScript libraries that can execute CQL artifacts expressed as JavaScript Object Notation (JSON) ELM.
- FHIR eCQM Examples: A website containing example eCQMs using FHIR.
- Measure Authoring Development Integrated Environment (MADiE): MADiE allows users to develop and test measures in an integrated workspace and supports QI-Core profile-informed authoring and testing of FHIR measures.
- Measure Authoring Tool: The Measure Authoring Tool was sunsetted June 28, 2024. Measure developers are to use the Measure Authoring Development Integrated Environment (MADiE).
- Visual Studio Code: An open source text editor. The ‘cqframework.cql’ extension supports highlighting, syntax checking, ad-hoc evaluation, test cases, and terminology for CQL and FHIR model validation. This free text editor environment can be used to facilitate measure evaluation and testing for eCQMs using the open source CQL Evaluation Engine.
FHIR Specifications and Implementation Guides
- FHIR Implementation Guide Registry: A list of many of the implementation guides defined by the FHIR community.
- FHIR Quality Measure Implementation Guide: The intent of the FHIR Quality Measure Implementation Guide (IG) or QM IG is to provide guidance on the representation of eCQMs using the FHIR Clinical Reasoning Module, Quality Improvement (QI)-Core IG, and CQL. It provides requirements for the use of measure structure, metadata, definitions, and logic when authoring and evaluating eCQMs.
- Data Exchange for Quality Measures Implementation Guide (DEQM): An HL7 FHIR IG to support value-based care exchange data. The intent is for DEQM to replace Quality Reporting Document Architecture (QRDA) Category I for individual reporting and QRDA Category III for aggregate reporting.
- Quality Improvement Core (QI-Core) IG: An IG, based on US-Core, that provides the data model for eCQM development and clinical decision support authoring. The intent for QI-Core is to replace QDM as a data model for eCQMs.
FHIR Testing Tools
- ClinFHIR: An open source tool that provides an educational environment and also allows developers to create or search for FHIR-based resources. It serves as a training tool to help people wanting to learn more about FHIR visualize how the parts combine to represent clinical information in a structured and coded manner. It also serves as a development tool with features to build some of the required artifacts, particularly as an aid to learning.
- FHIR Servers - Public Sites for Testing: HL7 provides a list of FHIR servers publicly available for testing. These are public services provided by volunteers and HL7 makes no representations concerning their safety or reliability.
- Postman: A collaboration platform for API development. Postman's features simplify each step of building an API and streamline collaboration so you can create better APIs—faster. The current use of Postman is for testing of FHIR-based eCQMs during HL7 Connectathons and provides a simple method for posting requests and updates to FHIR servers.
- CQL Runner: An online platform for ad hoc testing of CQL.
- Inferno: A rich and rigorous testing suite for HL7 FHIR to help developers implement the FHIR standard consistently. Two options are available for developers wanting to use Inferno. Use of the Inferno Program Edition is to help test requirements of the Standardized API for Patient and Population Services criterion § 170.315(g)(10) in the 2015 Edition Cures Update. The Inferno Community Edition contains a community-curated set of tests and tools for select FHIR Implementation Guides.
- Crucible: A suite of open source testing tools for FHIR provided to the FHIR development community to help promote correct FHIR implementations. It currently can test for conformance to the FHIR standard, score patient records for completeness, and generate synthetic patient data.
Test Data Tools
- SyntheaTM: An open-source, synthetic patient generator that models the medical history of synthetic patients. It provides realistic, but not real, patient data and associated health records covering every aspect of health care. The resulting data is free from cost, privacy, and security restrictions, enabling research with health information technology data that is otherwise legally or practically unavailable.
- Browse and download 1 million pre-generated synthetic records
- HL7 Downloads: HL7 webpage that contains examples, reference implementations, and other useful resources.
Introduction to Fast Healthcare Interoperability Resources® (FHIR®)
- Office of the National Coordinator (ONC) Fact Sheets - April 2, 2021
- Health Level Seven International® (HL7®) FHIR Fundamentals
Introduction to FHIR and eCQMs
- Reporting Electronic Clinical Quality Measures (eCQMs) Using the HL7® Fast Healthcare Interoperability Resources® (FHIR®) Standard Slides / YouTube / Q&As - July 1, 2021
- CMS Presents Quality Measurement using FHIR 101 Slides / YouTube / Transcript / Q&As - February 3, 2021
FHIR for eCQM Developers and Implementers
- FHIR based eCQMs: Human Readable Output - CMS Quality Bi-Monthly Forum Slides / YouTube - June 20, 2023
- eCQM FHIR Sparks Video Series (best viewed in order presented)
- What is FHIR? (YouTube) - YouTube Video Short - January 2022
- Anatomy of eCQMs in FHIR YouTube Video Short - January 2022
- Writing Measures in QI-Core: A Closer Look YouTube Video Short - February 2022
- Representing Encounters in QI-Core YouTube Video Short - April 2022
- Introducing the Quality Measure Implementation Guide YouTube Video Short - April 2022
- Authoring eCQMs Using the FHIR Standard Slides / YouTube / Q&As - April 15, 2021
- Visit the FHIR Community Forum.
- Join the HL7 FHIR Community.
- Join an HL7 Workgroup.
- Review the FHIR Confluence Wiki and the FHIR Blogs.
- Track progress on the Da Vinci project whose goal is to help payers and providers positively impact clinical, quality, cost, and care management outcomes.
- Send FHIR-related questions to fhir@icf.com.
- Submit feedback on FHIR issues, comments, and questions to the FHIR Issue Tracker.