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Fast Healthcare Interoperability Resources® (FHIR)

FHIR is a Health Level Seven International (HL7®) standard for exchanging healthcare information electronically. It is the next generation exchange framework being adopted by the healthcare community to advance interoperability. Electronic health records (EHRs) represent patient data in different ways (e.g., medications, encounters). 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 needs of a wide variety of use cases within the healthcare ecosystem. FHIR focuses on implementation and uses the latest web technologies to aid rapid adoption.

FHIR Quality Measurement

The healthcare 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 and 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. An eCQM is composed of three primary parts, the data model, expression logic, and structure.

eCQM structure graphic showing 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

Current eCQM and Potential eCQM FHIR Approach

FHIR eCQM uses the FHIR Quality Measure Implementation Guide, Data Exchange for Quality Measures (DEQM). The goal is to align quality measurement standards for eCQM development and reporting using FHIR:

FHIR

FHIR is composed of foundational, infrastructure, administrative, data-exchange, and clinical reasoning capabilities. The Clinical Reasoning Module of the current version, FHIR R4, 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 healthcare process prospectively and retrospectively. This module enables the same requests for information to be used 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, the FHIR Observation resource can be used to indicate anything observed about a patient. To indicate vital signs, a vital signs profile is required and 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.

Multiple profiles are often assembled into Implementation Guides (IGs) that can be easily consumed. As an example, QI-Core is an IG that contains profiles for representing the clinical data in an eCQM.

Exchange Specifications

The exchange specification defines how the resources are exchanged and managed. This can be achieved in the form of real-time Representational State Transfer (RESTful) application programing interfaces (APIs) as well as messaging and documents. RESTful APIs allow for the exchange of FHIR recourses 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/QUICK 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 healthcare 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 & clinical decision support
    • Both use a common FHIR data model (QUICK/FHIR QI-Core)

Health Level Seven International® (HL7) has many Fast Healthcare Interoperability Resources® (FHIR) resources located on the HL7® website including a FHIR® overview.

eCQM Related Tools for Use and Evaluation

FHIR Specifications and Implementation Guides

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.
  • Public Sites for Testing FHIR Servers: HL7 provides a list of FHIR servers that are 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 application programming interface (API) development. Postman's features simplify each step of building an API and streamline collaboration so you can create better APIs—faster.
  • 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 – Inferno Program Edition and Inferno Community Edition.
  • 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 healthcare. 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.
  • HL7 Downloads: HL7 webpage that contains examples, reference implementations, and other useful resources.

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.

Submit feedback on FHIR issues, comments, and questions to the FHIR Issue Tracker.

Last Updated: Jul 06, 2020