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.
- 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
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:
- 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
- DEQM individual and summary reporting replace QRDA I and QRDA III reporting.
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.
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.
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||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 (FHIR QI-Core)
The Office of the National Coordinator for Health IT (ONC) has created several FHIR Fact Sheets for use.
eCQM Related Tools for Use and Evaluation
- Atom Text Editor: An open source text editor. The ‘Language-CQL’ plug-in has functionality for Clinical Quality Language (CQL) syntax highlighting and Fast Healthcare Interoperability Resources® (FHIR) model validation. This free text editor is also capable of performing measure evaluation and testing for eCQMs using the open source CQL Evaluation Engine. Additional information is contained in the Atom User Instructions.
- Bonnie FHIR: A software tool that allows eCQM developers to test and verify the behavior of their eCQM logic. The Bonnie FHIR application allows measure developers to load FHIR measures they have constructed using the Measure Authoring Tool (MAT), helps measure developers execute the measure logic against the constructed patient test deck, and evaluates whether the logic aligns with the intent of the measure.
- CQL-to-ELM Translator: A tool for producing an Expression Logical Model (ELM) file format from 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.
- eCQM FHIR Examples: A website containing example eCQMs using FHIR.
FHIR Specifications and Implementation Guides
- Implementation Guide Registry: A list of many of the implementation guides defined by the FHIR community.
- FHIR Quality Measure Implementation Guide: The FHIR Quality Measure Implementation Guide (IG) or QM IG is intended to provide guidance on the representation of electronic clinical quality measures (eCQMs) using Fast Healthcare Interoperability Resources® (FHIR®) Clinical Reasoning Module, Quality Improvement (QI)-Core IG, and Clinical Quality Language (CQL). It provides requirements for measure structure, metadata, definitions, and logic to be used when authoring and evaluating eCQMs. As of March 2021, the published version of QM IG STU 2 (Standard for Trial Use 2) is based on the FHIR R4.
- Data Exchange for Quality Measures Implementation Guide (DEQM): An HL7 FHIR implementation guide to support value-based care exchange data. DEQM is intended to replace QRDA Category I for individual reporting and QRDA Category III for aggregate reporting
- Quality Improvement Core (QI-Core) Implementation Guide: An implementation guide, based on US-Core, that provides the data model for eCQM development and CDS authoring. QI-Core is intended 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.
- 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. Postman is currently utilized 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. The Inferno Program Edition is used 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 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.
- Browse and download 1M pre-generated synthetic records
- HL7 Downloads: HL7 webpage that contains examples, reference implementations, and other useful resources.
- Authoring eCQMs Using the FHIR Standard Webinar - April 15, 2021
- Office of the National Coordinator (ONC) Fact Sheets - April 2, 2021
- CMS Presents Quality Measurement using Health Level Seven® (HL7) Fast Healthcare Interoperability Resources (FHIR®) 101 Webinar - February 3, 2021
- Advancing Technology for Quality Reporting at CMS: Burden Reduction and FHIR - June 2020
- Exploring FHIR to Reduce Burden for Quality Measurement - April 14, 2020
- Introducing HL7 FHIR for Implementers webinar - January 22, 2020
- eCQI Resource Center Highlight: FHIR® Standard and Collaborative Measure Development Workspace - November 18, 2019
- MITRE FHIR Testing Tools presentation - November 27, 2018
Visit the FHIR Community Forum.
Join the HL7 FHIR Community.
Join an HL7 Workgroup.
Track progress on the Da Vinci project whose goal is to help payers and providers positively impact clinical, quality, cost, and care management outcomes.