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Setting care transfers on FHIR

From October, NHS hospitals are expected to use the new Transfer of Care standard to compile discharge summaries and clinic letters for GPs. NHS Digital has said these will be sent using FHIR messages directly into GP systems. Orion Health experts Dr David Hay and Anne O’Hanlon explain what this means for clinicians, hospital IT staff and vendors.

Fast Healthcare Interoperability Resources (FHIR) is the latest generation standards framework from HL7 International. It started at an HL7 meeting, when people said: ‘HL7 v3 is just too hard. We should be doing what the web companies are doing, and designing standards with the implementers in mind.’

What is different about FHIR is that it supports many paradigms of interoperability; you can use the same jigsaw pieces, known as resources, over and over again to solve different problems. It also uses web standards and interface patterns that emerged in other industries during the Web 2.0 era.

FHIR is a tool, not “the solution”

Designers are familiar with these, so they can focus on collecting data and using it in creative ways, instead of getting bogged down in the lingo of healthcare IT transfer formats. The risk is that people are starting to see FHIR as “the solution” and it’s not: there are plenty of other challenges.

For example, there is a common misconception that data captured in one clinical encounter will be fit for use for another clinical encounter; when, in reality, data quality may be poor, or data that is ‘good enough’ in one specialty may be of little or no use in a different specialty.

It may be sufficient for a pharmacist to know that someone has a cancer diagnosis, but an oncologist will want to know the exact tumour site(s), grade, malignancy, and so on. This kind of challenge is something that we need to keep in mind over the next few months, as hospitals and vendors get ready to implement the new Transfer of Care standard.

Transfer of Care and FHIR

English hospitals must use this standard to send structured, coded discharge summaries, emergency care discharge summaries, and outpatient clinic letters to GPs from October. In July 2017, NHS Digital announced that these documents would be sent using FHIR.

It specifically said that it did not want to use HL7 v3 CDA anymore because FHIR had become the “international industry standard” and the NHS would face “greater clinical risk and higher costs” if it undertook a complex migration to FHIR later.

We think this was the right thing to do, and we have been delighted by how people have engaged with the decision. However, to underline our point, it is not going to solve all the problems. Some GPs have told us that their local hospitals are sending PDF documents via NHS email yet they have not stopped sending paper copies in the mail, thus they end up re-reading letters they’ve already reviewed and actioned. Letting go of old ways of working takes time.

Now, they are going to have to create fully structured documents, using the headings developed by the Professional Record Standards Body and the Academy of Royal Medical Colleges, and pluck up the courage to stop using snail mail as a backstop. That is going to be a big change; particularly for outpatient departments, where letters are usually dictated.

We need an incremental approach  

Hospitals do seem to be engaging on the headings, but they have not moved as much on coding data. NHS Digital has mandated SNOMED CT as a structured clinical vocabulary for use in electronic health records, but it won’t become an NHS standard until 2020.

Likewise, medication data must become dm+d coded; which is a massive challenge given the current backdrop of paper-based prescribing and proprietary pharmacy formularies in many NHS hospitals. So, we think the October 2018 deadline looks optimistic, and there may need to be an incremental approach.

For example, we could define a minimally viable solution such as FHIR-ising a PDF document (carrying a PDF inside a FHIR message). There isn’t much direct benefit to doing that, but it would make the first milestone much simpler.

Also, if we started there, we could make sure that all the metadata was in the right place, and the content was sitting under the right headings. Then, we could gradually work on replacing the content with structured and coded data, which would enable a fully semantically interoperable FHIR document to be generated.

Safety is paramount and change takes time

Further reasons for taking this step-by-step approach are that patient safety is paramount and change management takes time. In New Zealand, we were involved in an e-discharge project some years ago, using HL7 v2. One supplier missed a field that could have been critical; if that hadn’t been picked up, it could have undermined confidence in the whole project.

From experience, we also know that when hospitals do medicines management projects they deliberately roll-out at a pace of one or two wards a fortnight. That’s partly so they can train around shift working, illness and holidays, and partly so they can get across what needs to be done differently and why that matters.

Sending Transfer of Care documents in FHIR will make it easier for diagnosis, allergy and medication data to be consumed, shredded and imported directly into the GP’s record (in addition to existing as a read-only document attached to the record).

This will reduce transcription errors and the time staff spend filing and re-keying information; but unless hospital staff grasp this bigger picture, they may just think they are being asked to do more admin. The IT system itself must also be simple enough to use so the focus of training and change management conversations is ‘why?’ and ‘what’s in it for me?’ rather than ‘click here and type this.’

Moving carefully in the right direction  

When it comes to sharing information, we are much further forward than we were five years ago. Back then, there were still arguments about who owned data, and what could be shared, and what standards should be used for any sharing that took place.

Another positive is that the Transfer of Care initiative is being driven forward in a very different way to previous standards adoption drives in England. Vendors, IT staff, clinicians, informaticians and industry experts have collaborated on a weekly basis to curate and design the information models, providing feedback on the practicality and potential problems of the standards before they are ratified.

INTEROPen has facilitated this engagement, meaning that the resources will be generic and reusable across many different clinical scenarios. However, with just three months to go, we are not sure just how ready hospitals and vendors are (and, of course, new issues will arise as actual implementations occur). NHS England has issued a survey to hospital trusts and is working with INTEROPen to issue a similar survey to vendors in the next few weeks.

All this is very positive, so we absolutely do not want to take our foot off the accelerator. However, we do need to understand that this is a journey; and that we will need to move forward incrementally.