Experiencing FHIR in the Swiss Healthcare System

Switzerland is highly innovative, but has some catching up to do when it comes to the digitalization of healthcare . Despite the many digital solutions in use, such as the Electronic Patient Dossier (EPD), practice management systems, and patient portals, information does not flow between these solutions. The administrative burden is increasingly overwhelming healthcare professionals. In this blog post, we’ll use an example to show you how standardization can help build bridges between isolated digital solutions and thereby speed up processes.

For 15 consecutive years, Switzerland has ranked first on the Global Innovation Index. This creates favorable conditions for leveraging the benefits of digitalization in the healthcare sector; however, Switzerland still lags behind in this area. Experience from Germany shows that standardization in the healthcare sector at the national level can only succeed if it supports relevant professional processes in a targeted manner. This requires interdisciplinary collaboration between legislators and national governing bodies as well as domain experts, such as service providers and manufacturers. In Switzerland, the national DigiSanté program is driving this initiative and represents a major opportunity to make data usable multiple times through standardization and to reduce administrative burdens. adesso Schweiz AG contributes its expertise to the success of standardization in the Swiss healthcare system. The case study demonstrates the role played by the Fast Healthcare Interoperability Resources (FHIR) standard from the international organization HL7 — the standard for the exchange of health data. In the following blog posts, we will explore the application of FHIR in more depth.

training and soon begins to feel severe pain in her right leg. Her orthopedic surgeon, Dr. Peter Meier, diagnoses a stress fracture in her right tibia but wants to have his diagnosis reviewed by a radiology specialist. Mara takes a data storage device, a referral, and accompanying printed documents with her and schedules an appointment. She goes to the radiology practice, where the data storage device is imported into the primary system. In addition, the relevant data from the referral and the accompanying documents are entered into the system. After the second opinion is prepared, Mara is given a data storage device and the printed medical reports. Mara then returns to Dr. Meier, schedules another appointment, and his practice now imports the data from the radiology practice and enters the relevant information from the paper documents.

However, there is a more efficient approach. Instead of giving Mara a data storage device and paper documents, Dr. Meier enters the request for a second opinion directly into Mara’s EPD. The radiology practice has all the relevant information optimally prepared in its primary system and can schedule work on the second opinion promptly. The results are uploaded to Mara’s EPD and are thus also available to Dr. Meier as quickly as possible in his familiar primary system. Mara no longer needs to coordinate appointments or act as an intermediary.

To ensure the smoothest possible communication between Dr. Meier’s practice and the radiology practice, the primary system vendor has opted for the international FHIR standard. In doing so, the vendor is investing in a promising technology.

In addition to FHIR, there are several other standards for exchanging health data. So why is FHIR the preferred data exchange standard in the healthcare sector in Europe and Switzerland? When data needs to be exchanged between different stakeholders in the healthcare sector, this is typically done over the internet. The representation and exchange of data on the internet is a problem that has already been solved. FHIR isn’t reinventing the wheel here. For data exchange, FHIR defines RESTful API, for example, and uses JSON or XML to represent the data, just like most services on the internet. This allows FHIR-based solutions to be easily implemented as cloud services, in mobile apps, and in telemedicine solutions. By using these widely adopted technologies, FHIR is also easy for developers to understand and implement. Developers have access to a broad, supportive development ecosystem.

As a platform standard, FHIR is designed to support the wide variety of healthcare systems worldwide. Different types of health data are represented by FHIR resources, which are generic templates for capturing clinical and administrative data. Resources can be adapted to specific use cases, such as obtaining a second opinion, and to regional characteristics, such as those of the Swiss healthcare system. These adaptations are described in profiles, which are summarized in FHIR Implementation Guides (FHIR IGs) and placed within a common context. This context could be, for example, the request for radiology findings. To make the FHIR IGs binding and maintain the quality of the standard, they are discussed and agreed upon with the relevant stakeholders through a proven balloting process. This ensures that the FHIR standard remains dynamic, extensible, and reliable in practice.

This level of flexibility is not provided by all other standards, such as HL7 v2, which is widely used for internal exchange within institutions. It exchanges data as messages via the MLLP protocol. For new developments involving exchange with other institutions over the Internet, MLLP should generally not be used, as all communication partners would then require an adapter solution outside the HL7 v2 standard. Furthermore, customizations in HL7 v2 are usually defined only locally, are not very standardized, and are poorly documented.

So how did Dr. Meier’s primary system provider implement FHIR to send the request for a second opinion to the radiology expert? Before writing his own FHIR IG and submitting it for review by the international FHIR community, he looked for a suitable FHIR IG that would work for requesting a second opinion within the Swiss healthcare system. In fact, HL7 Switzerland has already mapped this use case in the Swiss FHIR IG for radiology orders, “CH RAD-Order”. The CH RAD-Order IG defines a QuestionnaireRadiologyOrder for capturing the desired information, as well as a ServiceRequest resource for requesting the second opinion. In doing so, “CH RAD-Order” is based on the international, FHIR-based standardization for Structured Data Capture (SDC IG). The SDC IG defines how forms and questionnaires in the healthcare sector can be created, automatically pre-filled, and digitally processed. By linking to the international SDC IG, the Swiss FHIR IGs benefit from its improvements at the international level and make these IGs more interoperable. This avoids siloed solutions that cannot communicate beyond their local, cantonal, or Swiss borders.

Ideally, the radiology practice’s primary system has already implemented orders according to the “CH RAD-Order”. The QuestionnaireRadiologyOrder questionnaire may contain different content than what has already been implemented. However, the radiology practice’s primary system can generically implement FHIR questionnaires according to the SDC IG. This allows Dr. Meier’s request, for example, to be read from Mara’s EPD and displayed without modifying the primary system.

FHIR can therefore be implemented proactively in such a way that some extensions are possible easily and without downtime. For this to work smoothly, precise knowledge of the FHIR standard and a good overview of the use cases to be supported are necessary.

If the request for a second opinion between Dr. Meier and the radiology practice has not yet been implemented, the SDC IG or FHIR as a whole allows for some flexibility in this regard. The second opinion can be received in the form of an SDC IG questionnaire directly by the receiving primary radiology system, e.g., via RESTful APIs, as well as via, for example, a secure messenger, which was developed for the needs of the healthcare sector. A messenger may already have been introduced for other use cases and can now be extended for the processing of second opinions.

A double-edged sword: the various data transmission options give rise to a multitude of possible implementations, presenting manufacturers with challenges. Implementing all of these options can quickly become too costly. Which one, then, is the most economical and future-proof? Standardization can help keep the implementation effort for manufacturers and the costs for service providers within economically reasonable limits.

In addition to deciding on the transmission method—such as between RESTful APIs and Messenger—decisions regarding content are also necessary to make the FHIR standard more usable for specific use cases or conditions.

Two simple examples:

Should Swiss FHIR IGs only account for Swiss patients? To this end, the use of patient identifiers common in Switzerland, such as the EPR-SPID, can be mandated in the profiles. This clarifies that other identifiers may not or need not be implemented.

In the emergency room, patients may arrive unconscious and without identification. To ensure they can be admitted into the primary system, processing the name must be optional, for example. In the corresponding FHIR profile, the patient’s name can be marked as optional for this purpose. This helps vendors focus their implementation on what is strictly necessary.

With the help of FHIR, the relevant health data is available to Dr. Meier and his radiology colleagues in their familiar systems, automatically and without any disruption. Radiological images no longer need to be sent by mail, and patient data doesn’t have to be manually entered into a primary system. This saves time and reduces stress, and Dr. Meier and his colleagues are likely very happy about that. Even these small moments of joy can improve diagnostic accuracy and help avoid clinging to false hypotheses. Mara thus benefits twice over—from faster and better treatment. She can quickly adjust her training plan, and perhaps she’ll be fit again in time for the competition.

We are committed to the further development of FHIR and interoperability in the Swiss healthcare system as a whole. To this end, we are active in the interest groups HL7 Schweiz, IHE Suisse, IG eHealth, and BioAlps. As implementation experts, we love to inspire our customers with solutions that are truly valuable to them. FHIR is a crucial building block in this. So, let’s write your success story together.

While we’re giving you a glimpse here, we’ll dive deeper into selected aspects of FHIR-based interoperability in healthcare in upcoming blog posts. So be sure to check back here.