Edge of Tomorrow, aka why I’m not super-excited about FHIR

Yesterday evening my family and I went to see the new Spiderman movie (my wife has somewhat of a crush on Andrew Garfield). It was pretty good, although I still do not get why magnetizing the web shooters protected them against Electro. Whatever.

What really caught my eye was the trailer for Edge of Tomorrow, an upcoming show where Tom Cruise has to re-live the same day of battle over and over again (kind of like Groundhog Day but with aliens and Emily Blunt). The tagline is LIVE-DIE-REPEAT, and suddenly sitting there I realized --- this captures exactly why I’m so lukewarm about FHIR! (Seriously, that happened.)

In case you’ve missed it, FHIR is the shiny new thing in health interoperability circles. A lightweight, modular, composable, built-for-REST set of content standards to describe healthcare stuff. It’s clean, and there’s a lot to like about it. Why, then, do I find it so uninteresting?

Because we’ve been here before. At least a few times. And it’s always the same story, because standards folks only have one tool in their toolbox: make standards. Here’s what happens:

  1. The community defines a standard that is the state of the art for its time (HL7v2, IHE, Direct+CCDA, FHIR, etc.). People are excited!
  2. But adoption at scale is hard --- and it’s mostly not because of technology. Sure, we have to get through vendor upgrade cycles and we run into unexpected code issues, but that’s easy. What’s really hard is fitting use of the standard into daily workflows, solving privacy and trust challenges, navigating politics, and most importantly demonstrating economic value.
  3. Folks start slogging through the hard work. But it’s a long road, and takes time and persistence. People get disillusioned. Technical people get bored.
  4. Sadly, the standards folks don’t have tools to deal with most of this. But they want to do *something* to make things better … so they look at that last standard/technology and see where it could be better. Go directly to step #1. FOREVER.

We never get to spend enough time on the adoption part to make it stick before somebody creates a new shiny thing and we all run after it. I really thought that Meaningful Use would change this … we got such great buy-in around Direct and the C/CDA, it’s being implemented, every day more and more patients are really getting their data, the BB+ Push pilots are working…. But it’s slow, and we’ve certainly run into challenges.

So, here comes the new standard to save the day. But even if this one is a little better technically --- and I’d wager it is --- that won’t matter. It’ll have its own set of scale adoption issues. What’s the service URL for each provider? How do you register each app with each provider’s OAuth endpoint? Are there policy requirements before somebody allows your app “in”? Anybody hear about something called Covert Redirection? What about push events; are we all going to be polling each other for new data all the time? And on, and on, and on.

The really sad thing is that I have to take some blame for this with Direct too. I thought we could break the cycle by including ideas like distributed “circles of trust” --- a system whereby once you’ve installed Direct, you can expand your trading partners over time without any technical changes. This is working, but not fast enough … the cycle of frustration with things like the Federal Bridge and arguments over identity proofing risk sending us right back to the starting line.

I don’t have an answer. And you know, if FHIR gains traction you can count on HealthVault to implement it --- our model fails without interoperability, so we have no choice but to play along. I just can’t force myself to get excited about the standards any more. As my good friend Umesh always says … old wine in new bottles.

All that said, the movie looks like a lot of fun.