Draft Action Plan Summary

The FHIR Action Plan promises to serve as a guide to the FHIR-based capabilities being used by the federal government today, but it is primary a list of specifications by area and their relative maturity, with very general advice about which IG to use. It’s limited to FHIR use cases in use or in consideration for the next 2 years. It doesn’t mention what federal agencies are using or plan to use in any detail. In terms of current capabilities, it just directs interested health IT developers to HELIOS. Those developers can use the list to guide their efforts towards the most mature use cases for the next 2 years.

The section called “FHIR Ecosystem” lists the specifications: FHIR Ecosystem | Interoperability Standards Platform (ISP). Note that they're looking for feedback on the guidelines, NOT on the implementation guides.

APHL Feedback

We are writing on behalf of the Association of Public Health Laboratories (APHL), an organization that works to strengthen laboratory systems serving the public’s health in the US and globally. APHL member laboratories-state and local governmental laboratories in the US protect the public’s health by monitoring and detecting infectious and foodborne diseases; environmental contaminants; biological, chemical, and radiological agents; genetic disorders in newborns; and other diverse health threats.

APHL appreciates the opportunity to submit feedback on the Draft FHIR Action Plan.

General feedback: the UI of the ONC FHIR Draft Action Plan is cumbersome. The ONC FHIR Draft Action Plan relies on many external links, an approach which may confuse the end user as to the scope of what is covered by its guidance.
Identifying the Core Components based on US Core is on target and a good approach, but it neglects the fact that US Core elements apply to EHR-S and do not necessarily cover all the other data producing systems for all use cases that need to be supported by federal agencies. In addition, the approach for inclusion in USCDI generalizes several data elements into categories that are not reflective of data modeling in those systems, and more documentation is needed to properly define each of the data elements so they can be reused without fear of misinterpretation. Of note is that US Core elements called out in regulation are usually 3 years or so behind the latest US Core version reflecting the last published version of USCDI.
Note that eCR data exchange is highly reliant on an intermediary, the eCR FHIR App on the APHL AIMS Platform. This app converts incoming eCR from healthcare organizations to CDA, and that is the format that is currently received and ingested by most public health agencies. As APHL recently recommended in our comments on HTI-2, ONC should clarify that the use of intermediaries like AIMS is an important component of public health reporting and is an acceptable way to meet requirements.
APHL recommends that ONC not list the Cancer Pathology Reporting IG as ready to use at this time. This IG is not mature enough for production. Currently, public health must combine data received from the Central Cancer Registry Report and the Cancer Pathology Report (which are defined by two separate IGs) in order to form a complete cancer case. The HL7 FHIR Cancer Registry Reporting Workgroup are working with eCR leads at CDC to implement cancer reporting of the cancer registry incidence report, then use eRSD and RCKMS to support the time interval reporting of additional information on the case. It may be prudent to wait for these changes to be implemented before identifying the IG to use in this scenario.
Many eCR exchanges with public health currently involve (and will continue to leverage) CDA-to-FHIR and/or FHIR-to-CDA transformations. These transformations are critical to enabling PHAs to pursue FHIR readiness without disrupting existing dataflows. Many of the resources, tools, and capabilities that are being developed by APHL and others are in support of these transformations and are aimed at allowing the PHA to use eCR content.
APHL recommends that ONC encourage trading partners to implement eCR Implementation Guide Version 2.1.2. While the draft FHIR Action Plan identifies V.2.1.0 as “most ready for adoption in certified health IT,” it is APHL’s experience that few trading partners are using 2.1.0 currently, so new implementations should focus on the latest implementation guide.
Under Early-stage Capabilities, APHL suggests modifying the following statement to apply more broadly: “The response to COVID-19 has demonstrated the need to make data available and able to be exchanged efficiently across the healthcare system.” should read “The response to COVID-19 as well as other public health emergencies such as Mpox has demonstrated the need to make data available and able to be exchanged efficiently across the healthcare system.”