1 digital health record to rule them all

FHIR and tomorrow’s digital health infrastructure

The old digital health paradigm has exploded. Let’s look at the numbers. We are coming off of a record-breaking funding year for digital health startups with $14.8 billion in venture capital funding flowing into the space in 2020 – a 66% increase from the $8.9 billion invested in 2019. We are seeing huge growth in patient utilization and revenue. 2021 may mark the first year of a gilded age for healthcare technology. Digital health startups used to be forced to sell their solutions to incumbents. This is now changing. Startups are now launching virtual clinics, clinical decision support solutions, and personalized medical solutions. This new class of digital health startups is not out to simply support traditional providers but to compete directly against them. This is a great development for patients because it will lead to improved quality of care. But something important is missing.

This is a photo of Billy Joel from the music video for “We Didn’t Start the Fire”. This will *hopefully* make sense very soon.

The current infrastructure needed to support this rise of digital health solutions is insufficient. New digital health startups require backend infrastructure that legacy healthcare IT systems cannot deliver on. Here’s why. Old backend “health IT” was built largely for solely accounting purposes. Most EHR/EMRs are glorified excel accounting systems wrapped in horrible UX/UIs. The focus was different. Legacy digital health infrastructure was built at a time where fee-for-service was king, patients were not the end-user, and interoperability was a threat. So where does that leave us?

Today most digital health companies are building their entire digital tech stack from scratch from the ground up. A minority of digital health startups are licensing off-the-shelf systems and pouring in time and money to customize them to do what they need. This highlights a huge opportunity. There is now enough demand for a whole suite of startups to build the new tech stack for digital health. But where to start?

At Automate Medical we believe the catalyst for the digital health revolution on the horizon is data interoperability. If there is going to be a rise in tools like Plaid or Stripe in healthtech, we must first resolve the interoperability problem in digital health. To ensure interoperability we must have substantially better developer tools for health data. Interoperable systems can only become easier to build if the architectures, frameworks, and tooling we use to build them are developer-friendly. And it turns out that we don’t need to boil the ocean to get there.

Better interoperability solutions already exist and are gaining traction quickly. HL7, the health care data standards organization, maintains a specification called FHIR (Fast Healthcare Interoperability Resources), a standard for exchanging healthcare information electronically. FHIR, pronounced fire, is a standard describing data formats and elements, known as “resources”, and an API for exchanging electronic health records. Resources each have a tag that acts as a unique identifier, similar to the URL of a web page.

Think of it this way, when you go to a website, like Shopify for example, your browser line will say “HTTP” and then have a string of words and numbers that follow it. That’s because it’s a query-retrieve system generated in your browser and sent to Shopify. Shopify receives the query and instantly returns the results securely. Everyone and anyone in the world with access to the same URL can complete the same task/s using any browser running on any internet-enabled device — whether it’s a desktop, smartphone, or tablet running an Android, Apple, Windows, or Linux operating system. FHIR allows developers to build standardized browser-like applications that allows access to data, regardless of which exact electronic health record operating system underpins that user’s infrastructure.

So why are developers, payors, providers, and patients so fired up about FHIR? **Sorry, I had to.** Well, because FHIR may be a key piece to ensuring that the digital experience in healthcare is what we all wish it was. With FHIR, wearables and monitoring tech can become worthwhile from a clinical perspective. While the healthcare IoT universe continues to explode, there hasn’t been an easy way for patient-generated health data to sync with provider or payer workflows. With FHIR, clinical decision support systems are no longer constrained by siloed data access across multiple EHRs and health networks. Patient data spread across multiple providers and systems can sync into one single health record. This single health record can integrate patient-generated data and provider-generated data stored across multiple institutions and formats to deliver a complete computable patient history. We can do this. The technology is already here.

Let’s break this down. Say you have shortness of breath. Uh oh. You go to a walk-in clinic in your hometown and get a prescription for an inhaler. While on vacation a few hours away from where you live things get worse, so you go to an urgent care center. You get referred to a specialist in your hometown. You see that specialist for a few years and they try a bunch of different things. You’ve now moved again, and while scrolling through Instagram you see an ad for a virtual care offering that seems promising. You book an appointment. One of the first things you’re asked during the appointment is for your medical history. You say you thought they could just pull it all up. You get a blank stare from them. You give them a blank stare back…So what happens now? Well, without FHIR you may as well get a second job trying to track down all your medical data from the different doctors and health systems you visited and if you do get it, your records will likely be provided weeks later on various CDs, 70-page faxed printouts, or maybe, if you’re lucky, a USB stick. Bad for you, bad for that new virtual care startup that wants to help.

The future tech stack in digital health will have the UX/UI we expect in 2021 and beyond. We don’t care about our phone’s interface as much as we care about the third-party apps we rely on (except maybe for blue iMessages). We don’t use email clients written specifically for Apple or Android -- Apple and Android provide the platform itself. This is the direction the digital health tech stack is moving; a move away from a Swiss Army knife approach to a platform with lots of applets sitting on top of it. And our bet at Automate Medical is that the digital health platform of tomorrow will have FHIR at its core.

…it was a FHIR/fire joke.

The goal of digital health is to deliver high-quality and affordable care at scale. Machine learning and data science will take on tasks that have historically been done by humans and/or expensive legacy health IT products. Digital health startups are unnecessarily wasting capital and time developing the same data infrastructure components, again and again, across each of their own walled gardens. This does not scale. FHIR enables digital health companies to be agile, cost-effective, and scale rapidly. Instead of walled data gardens, open-source projects like what we are building at Automate Medical will usher in transparency and scale. FHIR enables a single interoperable digital health record. The future is already here, it's just not evenly distributed...yet.