February 2016

Imaging Informatics: Catching FHIR — Improving Interoperability to Exchange Forms Data
By David Yeager
Radiology Today
Vol. 17 No. 2 P. 6

Nearly everyone in the IT field agrees that interoperability is needed to propel value-based care, but making it happen isn't easy. Getting patient information, such as medical images and radiology reports, to health care providers is essential, but allowing patients to take ownership of their medical data will become increasingly important. When it comes to efficient information exchange, more work is needed.

"In the world of interoperability, and in a world where the patient is important, we're still living in the 20th century," says Shafiq Rab, MD, CIO and vice president of Hackensack University Medical Center (HUMC) in New Jersey. "[In most cases] patient information cannot move from one side to the other without having a painful process of developing an interface and working for months to understand it."

To help address these difficulties, HL7 International developed the Fast Healthcare Interoperability Resources (FHIR, pronounced "fire") specification, which is a Web-enabled standard for the electronic exchange of health care data. A new product called Forward, which was debuted by MphRx at RSNA 2015, is one of the first commercial products to use the FHIR standard to transmit patient forms, medical images, and reports from any computer or mobile device to any EHR, PACS, or RIS.

A Tighter Loop
Forward generates a library of customized patient forms that can be completed online and enables the upload of DICOM or non-DICOM files, documents in a range of formats, and continuity of care document data. All form data are captured and stored in the FHIR standard. Forward can be used by radiologists or other physicians, as well as patients. It can be implemented on site or through MphRx's cloud service.

MphRx has also built a FHIR-based platform called Minerva to address data exchange between multiple systems. Minerva acts as a staging area for data so they can be reviewed before transmission to an endpoint system. It has physician and patient portals that are bidirectional and HIPAA compliant, with two-factor authentication.

One way that Forward and Minerva assist physician-patient communication is by automatically sending questionnaires to patients prior to their appointments. The questionnaires are customizable and may relate to items such as registration, current medical condition, medical history, demographic information, or insurance information. One advantage of automation is that it reduces data inaccuracies and omissions and reduces the need for hospital staff to handle the data.

"Whenever an appointment is scheduled for a procedure or MRI or CT, depending on the procedure code, Forward can be programmed to pick the questionnaire and send it over to the patient," says Varun Anand, the cofounder of MphRx. "The patient then receives an e-mail link and also a text message with a secure PIN [personal identification number] code. The patient can open up the questionnaire on their iPhone or Android device or any mobile device. They can also open it up on their computer without installing anything. It's completely Web-driven, so it's all done with HTML5."

Forward can also be embedded in a hospital or practice website so new patients can receive the appropriate forms after they have registered with a physician. When patients open their link, they see their demographic screen, which they can edit themselves. They can then fill out the questionnaire. Questionnaires can be broken into question groups to make them more user friendly. Long questionnaires can be filled out in sections without losing data, rather than in one long sitting.

When patients are finished, they can upload their documents or medical images. Images are sent to PACS as a DICOM-structured report object of a DICOM image snapshot, and information is sent to the EHR through HL7 or a programming interface. Once the information is updated, it's updated in all of the repositories containing that patient's data that are linked to Minerva.

It took HUMC about two weeks to test and implement Minerva. Rab says the ability to fill out forms at home has significantly reduced patient wait times. Without FHIR, he adds, a system like this would not be possible. He says the system is simple and easy to use, and that patient response has been positive.

"Patients are using it. They're putting their forms in it. When they come in, they don't have to wait," Rab says. "For us [at HUMC], the best part is that [the system] makes it easier for us to treat our patients as we would treat our family members, with respect. This is one facet [of health care delivery] that is trying to complete the [care] loop, such as having all of the patient's information up front, keeping it updated, checking to make sure appointments have been made, or whether the appointment has changed. All of those things that we were never able to do before are now possible because of technology."

Trickle-Down Interoperability
As patient satisfaction and collaboration become more important in health care, interoperable technologies will be indispensable. Many large and midsized medical centers are upgrading the interoperability of their systems, but smaller health care providers may not have the resources to upgrade aggressively. Anand says helping these providers share data quickly and easily will be an important step. He thinks the FHIR standard will be a key part of the process.

"Smaller entities, like community hospitals, that receive data from physician practices and imaging centers might not, on a per unit level, have the high patient volumes to justify investing in a digital interface, but collectively managing the patient volumes that are coming from those hospitals—that's a true interoperability challenge," Anand says. "How do you offer a solution that provides true interoperability without making a huge investment in point-to-point integrations? More importantly, when a patient walks into an imaging center, instead of making them fill out the same forms over and over, are you able to use the referring physician's data to get the forms beforehand so that those responses are captured electronically in a manner that doesn't bother the patient too much? I think it's a very good time in the industry to talk about this because we're seeing a lot of initiatives in the marketplace and a lot of technologies that have made a significant impact with this specific approach."

— David Yeager is a freelance writer and editor based in Royersford, Pennsylvania. He writes primarily about informatics topics for Radiology Today.