January 27, 2023

FHIR – a choice or a necessity?

By Archana Dhaka and Swetha Raman Chakravarthy, MHI Program, IHPME, University of Toronto

Canadian healthcare system has functioned in silos for a long time and the pandemic uncovered multiple layers of a strained healthcare delivery. To combat it, the system witnessed an accelerated digital health transformation in a short span of time. Currently, virtual care use has reached 1.5million consultations per year, hospitals have accelerated implementation of comprehensive EMRs for timely information sharing, primary care has adopted electronic referrals and patients can access their health information through patient portals. Despite this tremendous progress, there are challenges in healthcare delivery due to lack of interoperability. Digital health information still seems to be siloed, trapped in a PCP’s EMR or a hospital’s CIS. For instance, a patient’s access to health information is available only if they are receiving care from the same organization or an integrated system or group of clinicians. Otherwise, they are required to communicate all relevant information related to their medical history, profile, and medications at each point of care as they navigate the system. Communication of patient’s status between clinicians, hospitals, nursing homes, and sharing of patient summaries or test results is limited and inconsistent. Hence it is imperative to improve digital connectivity while adopting newer systems and technologies at point of care, which is heavily reliant on interoperability.

HIMSS defines interoperability as the ability of multiple technologies to access, exchange, integrate and cooperatively use data in a coordinated manner, within and across organizational, regional, and national boundaries, providing timely and seamless health information exchange (HIE) and optimize the health of individuals and populations globally. Exchange is key, and this is determined by the type of interoperability standard adopted across all systems. One of the highly sought interoperability standards to facilitate structural and semantic interoperability is FHIR- Fast Healthcare Interoperability Resources.

Current State                                                              

In the past 20 years, Canada has made significant progress in interoperability and has escalated exponentially in the last three years. Many organizations moved from simple standards like HL7 v3 or CDA to SMART on FHIR specification. Canada Health Infoway is constantly developing Pan-Canadian approaches to extend FHIR capabilities and is currently in its nascent stages.  For a point-to-point data exchange across whole healthcare system, we will need a deep integration model.


FHIR Implementation architectures: www.healthcatalyst.com 

Why FHIR In Canada?     

  • Dynamic: FHIR can accommodate new developments without deviating from its core principles. Modifications and upgrades can be suggested without compromising or hindering current implementations, but rather by enhancing them in ways that are significant and beneficial.
  • Practical relevance: Instead of requiring users and systems to adhere to a predetermined set of rigid perspectives, FHIR provides the capability to reference objects in the manner they are referenced in the real world.
  • Universal: Open APIs of FHIR enable rapid building of healthcare data interfaces, thus minimizing barriers to data exchange. Developers and vendors can use this resource-based standard to create platforms that can comply with healthcare data models, addressing some of the biggest healthcare challenges such as patient engagement, interpractice data exchange and intelligent clinical decision support. For example, a doctor’s application can be used by other doctors, and a hospital’s application can be used by all hospitals.
  • Compatible with legacy systems: FHIR makes use of modern standards without limiting users to legacy systems. Users can transition smoothly to FHIR standards without any system restrictions. FHIR uses existing logical and theoretical models that facilitates easy implementations, while preserving information integrity. It improves implementation capabilities by utilizing modern web technologies such as JSON, XML and REST and lets systems to share unstructured data, that comprises up to 80% of all health data.
  • Long term Integrations: Accelerated FHIR capabilities can make systems work together quickly and effectively, while planning and executing long term integrations.
  • Connected Care: Lastly, FHIR provides a mechanism to identify patients, clinicians, destinations and can find, transfer data back and forth between different systems, in real-time and on-demand. SMART on FHIR apps can pull in data from almost any EHR and drives a connected care.



Studies conducted in Australia and USA have shown that both providers and society accrue benefits from implementation of FHIR. According to a study conducted in Australia, the net steady-state benefits of implementing FHIR were estimated to be $2050 million, with rollout costs of $14.2 billion and annual steady-state costs of $933 million, while accounting for transactions involving laboratory, imaging centre, pharmacy, and public health. The European Union’s InteropEHRate and India’s Digital Health Blueprint efforts focus on implementing FHIR-based personal health records and data sharing with providers. FHIR has gradually emerged as the global interoperability standard for exchanging health data among systems which necessitates accelerated FHIR adoption in Canada. However, Ontario Regulation 569/20 does not mandate the use of standardized APIs developed using FHIR or require FHIR in the APIs certification criteria.

How will it benefit stakeholders?

The adoption of interoperability ubiquitously will yield substantial benefits for patients, providers, vendors, and government. Patients will have more access to personal data as a result of growing FHIR adoption and the implementation of policies that restrict information blocking (such as 21st Century Cures). Consequently, a growing number of tools could be developed to help patients better organize, derive insights, and improve their health by aggregating health data from various providers. Patients can access their medical records through patient portals provided by the industry leaders in healthcare software, EPIC and Cerner, all of which are based on HL7 FHIR. Furthermore, Apple Health enables users to simply extract and share health information data from wearables with others based on FHIR standard. FHIR may encourage collaborations with software developers to discover novel solutions for clinical problems and frustrations that only existed because of inadequate information sharing between incompatible systems, which could benefit both physicians and patients.

FHIR can make a tangible contribution, but only if all involved stakeholders are properly informed and educated on how to safeguard interoperability while developing and deploying FHIR-based solutions. Adoption of FHIR will reduce administrative burdens on providers, improve price transparency, and information accessibility for patients, their circle of care, and the wider healthcare community. Through the introduction of FHIR, EHR vendors have a unique opportunity to enhance customer retention and growth while also enabling their clients to realize strategic benefits. From the standpoint of policy, it is essential to send strong signals that interoperability by design is the way to go. The implementation of incentives that guide and stimulate both the supply and demand is necessary.

Canadian Healthcare lags in leveraging transformational capacity of the internet, which proved vital in the past two years. Although all stakeholders have been longing to have interoperable healthcare, it has been slow in coming. FHIR can be the game changer and the driving force for Internet of Health. Technological innovations with FHIR will lead to true interoperability in healthcare, with an effective exchange of patient information for better patient care, patient safety, care coordination and collaborative clinical decisions.

This article is shared by permission of the authors: Archana Dhaka and Swetha Raman Chakravarthy. Learn more about University of Toronto Institute of Health Policy, Management, and Evaluation Master of Health Informatics Program here