In 2018, the United States was at a tipping point with respect to the adoption and implementation of the Health Level Seven (HL7®) Fast Healthcare Interoperability Resources (FHIR®) standard in health information technology (Health IT). At that time, our analysis, outlined in a previous blog post predicted that the US could soon see widespread adoption of certified FHIR-enabled application programming interface (API) technology. The results are available and the findings are encouraging.
America is catching FHIR
In 2018, we estimated that 87% of hospitals and 69% of physicians had certified technology with a 2015 edition version enabled with FHIR. These rates were not a prediction of who would adopt FHIR-enabled technology in 2019, but rather served as an estimated upper bound of who might upgrade your certified technology to a FHIR-enabled 2015 Edition in 2019. Today, a new analysis shows that observed technology adoption rates were very close to these estimates.
As of 2019, 84% of hospitals and 61% of physicians adopted and implemented FHIR-enabled 2015 Edition certified API technology (see Table 1). We found that 97% of hospitals and 88% of physicians that we predicted in 2018 could adopt this technology did so in 2019.
Table 1: Percentage of hospitals and physicians that adopted or could adopt (but did not do so) FHIR-enabled 2015 Edition certified API technology, 2019
|% adopted|| % could adopt
| % adopted or
Notes: (1) All non-federal intensive care hospitals in the US (2) All types of physicians eligible for the Merit Based Incentive Payment System (MIPS). (3) Could Adopt represents the percentage of hospitals and physicians that have not adopted 2015 Edition technology but have certified technology with a 2015 Edition version enabled with FHIR.
Furthermore, we found that 91% of hospitals and 72% of physicians have adopted or could adopt FHIR-enabled 2015 Edition certified technology, a small increase from the 2018 estimate. This means, in addition to hospitals and physicians that adopted technology in 2019, another 7% of hospitals and 11% of physicians. might upgrade to FHIR-enabled 2015 Edition certified technology from your current healthcare IT developer.
As in the previous analysis, technology adoption by market-leading developers comprises most of this trend. Table 2 shows that 83% of hospitals and 58% of physicians adopted certified API technology from a market leader in 2019. This accounted for 99% and 95% of all FHIR-enabled technology deployments, respectively. . The findings show that healthcare IT market leaders, who are all FHIR compliant, drove much of the adoption of certified FHIR-enabled API technology in 2019.
Table 2: Percentage of hospitals and physicians adopting and implementing certified API technology from market leaders (all support FHIR), 2019
|developer||% hospitals||% doctors|
|Epic Systems Corporation||32%||35%|
|All market leaders||83%||58%|
The following maps show that adoption of FHIR-enabled technology is widespread in the US However, looking beyond these national estimates, we see geographic variation in deployments in the US.
Figure 1 shows that hospitals in most regions are at or above the national average of 84% and some regions show that 100% of hospitals have implemented FHIR-enabled technology. It is important to note that hospitals in some regions lag behind, such as in the southwest and west of the mountains.
Figure 1: Percentage of All Hospitals Adopting and Implementing FHIR-Enabled Certified API Technology in 2019, by Healthcare Reference Region (HRR)
Notes: The map shows the borders of the Healthcare Reference Regions (HRR). The gray areas are regions with no known hospitals.
Figure 2, centered on physicians, shows a similar story, albeit one of much less widespread adoption than that of hospitals (as also shown by national averages). However, most regions are performing on average with some variation in certain regions, particularly in the mountainous west.
Figure 2: Percentage of All Physicians Adopting and Implementing FHIR-Enabled Certified API Technology in 2019, by Healthcare Reference Region (HRR)
Notes: The map shows the borders of the Healthcare Reference Regions (HRR). The gray areas are regions with no known physicians.
The trend is expected to continue
The Final Rule of the ONC Cures Act 2020 requires the use of FHIR Release 4 as part of the new certification criteria adopted in 45 CFR 170.315 (g) (10), Standardized API for Patient and Population Services. Additionally, as required by API Condition and Maintenance of Certification in 45 CFR 170.404 (b) (3), software developers with health IT previously certified for API technical compliance must provide all customers with enhanced API technology. certified for this new certification criteria by no after December 31, 2022.[1-2] The good news is that while updates from FHIR Release 2 to Release 4 are likely to be required in many installations, many certified API developers and all leaders in the healthcare IT market already support the FHIR standard.
Data shows that, as of 2019, the majority (84% of hospitals and 61% of physicians) have adopted and implemented certified FHIR-enabled API technology. This means that third-party developers can connect to the EHRs of these providers using standardized FHIR APIs and health information can flow using the data standard. Not all vendors adopted and implemented certified FHIR-enabled API technology in 2019, but for those that did, the results are encouraging.
We expect these rates to increase as more hospitals and physicians adopt and implement the Cures Update 2015 Edition and more certified API developers move toward supporting the FHIR standard. The data shows that most healthcare providers have implemented these standards-based technologies, and we project more to follow soon. This data should encourage efforts to expand the use of FHIR among data and technology users.
 Law of Cures of the XXI Century: Interoperability, Information Blocking and IT Certification Program of ONC Health. 85 FR 25642. https://www.federalregister.gov/documents/2020/05/01/2020-07419/21st-century-cures-act-interoperability-information-blocking-and-the-onc-health-it- Certification. Consulted: February 19, 2021.
 Information Blocking and the ONC Health IT Certification Program: Extension of Compliance Dates and Deadlines in Response to the COVID-19 Public Health Emergency. 85 FR 70064. https://www.federalregister.gov/documents/2020/11/04/2020-24376/information-blocking-and-the-onc-health-it-certification-program-extension-of-compliance-dates-and. Consulted: July 27, 2021.
Data sources: Data from the 2019 Medicare Interoperability Promotion Program; ONC Certified Health IT Product List (CHPL); Service Provider File from Centers for Medicare & Medicaid Services; Downloadable National Archive of Doctors and Clinics.
Methods: In 2019, the Medicare Interoperability Promotion (PI) Program required the use of certified EHR technology 2015 Edition by hospital participants and physicians for the first time. This technology included certified APIs, too, for the first time. We compared the 2015 Edition Certified Health IT Module Lists on the Certified Health IT Product List (CHPL) with the certified EHR technology reported by Hospital and Physician PI Program participants in 2019. An analysis of the Certified API technology documentation available through CHPL confirmed a module support certificate for FHIR. Therefore, we use 2019 officially reported certified technology data to verify technology adoption and CHPL API documentation data to confirm FHIR support among reported certified technology. Therefore, the data may insufficiently represent the actual adoption of certified API technology that is not officially reported through the PI Program.
For the original 2018 blog, we analyzed the CHPL 2015 Edition Certified Health IT Module Lists and Physician and Hospital Certified Technology Adoption Data, prior to the start of the 2019 PI program year, to model the likely implementation of FHIR-based APIs among these health services. care providers. This was a prospective analysis that sought to model how the requirements to adopt the 2015 Edition certified API technology could be met in 2019. Now, using data from the 2019 PI Program and an updated analysis of the API documentation available through the CHPL, we can quantify the percentage of hospitals and physicians that implemented and reported the use of certified FHIR-based API-enabled technology in 2019.
Hospitals: All non-federal intensive care hospitals in the US.
Doctors: All Medicare-enrolled Merit-Based Incentive Payment System eligible physician types.
FHIR enabled technology: Certified health IT modules that reference the FHIR standard as part of their official API documentation associated with your CHPL discoverable health IT certificate.
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