The Argonaut Project has a big, maybe even audacious ambition: to make health data-sharing easier by using Internet-based open messaging and documents standards instead of complex, healthcare-specific ones.
The project's champion, John Halamka, is one of the best-known figures in health information technology. He's the CIO of Beth Israel Deaconess Medical Center, a full professor at Harvard Medical School, the chairman of the New England Health Electronic Data Interchange Network (NEHEN), co-chair of the HIT Standards Committee, and a practicing emergency physician. Under his leadership, in 2012 Beth Israel Deaconess was the No. 1 company in InformationWeek's innovation ranking. His Life as a Healthcare CIO blog is a "must read" for any serious follower of the health IT landscape. As if that weren't enough, he is also an active farmer who raises various species of animals and grows multiple crops at Unity Farm in rural Sherborn, Mass. (See photo below.)
Last month, Halamka announced the Argonaut Project, which essentially proposes to use an expansion of the rapidly emerging Fast Healthcare Interoperability Resources (FHIR) data-exchange standard to replace the Consolidated Clinical Document Architecture (CCDA) -- the complex (some would say overly complex) set of XML-formatted clinical documents worked out over a number of years by the HL7 standards body (FHIR is also part of HL7). I'm a strong proponent of FHIR, and I've seen just how challenging CDA is, even for my talented Georgia Tech graduate students, so I could hardly wait to talk to John about this exciting project.
MB: John, as an avid foodie I am as tempted to ask you about your farm as about The Argonaut Project, but this a health IT column, so let's start with where the idea for the Argonaut Project came about.
JH: Well, interestingly, there is a food connection there, too. A group of us were at the October meeting of the joint standards and policy committee, and at dinner over Greek food we discussed how to move forward with industry in implementing the recommendations of the JASON Task Force that had been so ably chaired by David McCallie and Micky Tripathi. The name of this effort was fairly obvious given Greek mythology. All agreed that we needed a broad group of stakeholders from both healthcare and the HIT industry.
[What are the top health IT challenges ahead? See Health IT In 2015.]
MB: What is the basic goal of the Argonaut Project?
JH: There are really two key goals. We propose to replace healthcare-specific document and messaging standards with the more universal and essentially free equivalents taken from the Internet.
As you've implied, the first goal is to provide a more facile, easier to implement means of sharing key groups of clinical data (e.g. documents) that are required in common clinical scenarios. CDA is a healthcare-specific approach to creating electronic documents. FHIR has already taken advantage of JSON (or XML) objects as a means of packaging what are essentially sections of documents. Why not go all the way and use sets of FHIR JSON objects in place of complex CDA documents?
The initial use case is transitions of care -- when a patient is referred from one institution or provider to another, such as a hospital discharge to the care of a private physician or to a subacute or long-term care facility. At present, the XML-formatted Continuity of Care Document (CCD) is the standard specified under Meaningful Use in such situations. It is also widely used to meet the Meaningful Use "view, download, transmit" (VDT) requirement giving patients access to their medical records.
The problem with the CCD, as your students [at Georgia Tech] have learned, is that it is actually an extremely complex document. Moreover, it is rather loosely specified, so CCDs can vary substantially based on the EHR that produced them.
We propose to extend the FHIR to encompass the entire Meaningful Use common dataset. This would be done within the FHIR framework, which seeks to prevent individual resources from becoming overly complicated, so any needed new data would be spread out to appropriate existing resources and some new resources might be defined. FHIR is an emerging standard that encourages extensions, so this, too, is in keeping with the spirit of the standard.
Second, to replace healthcare-specific messaging standards, we would develop a new FHIR REST GET API that could be used by organizations to request the equivalent of the CCD. The result would be a set of FHIRs that, in total, provide the same information that is in the current CCD specification.
MB: One of these healthcare-specific messaging standards is Direct -- a simple, inexpensive means of sharing CDA documents as well as other formats for conveying health information among providers. Do you see Argonaut replacing that in time?
JH: Yes, over time, I believe Direct will prove to have been a transitional technology, but one that first introduced the notion that, while healthcare has its own unique vocabulary, and these data standards are a part of FHIR, just as they were a part of CDA, it need not develop its own messaging standards. Nothing could be simpler and less expensive than using the same messaging standards that are commonplace on the Internet. Everyone else is sharing information this way, why shouldn't healthcare?
MB: I was struck when Argonaut was announced that you had four of the major enterprise healthcare vendors -- McKesson, Cerner, Epic, and Meditech -- as collaborators. Was this hard to do?
JH: Surprisingly to many, I imagine, no. The vendor community has struggled with Meaningful Use and Stage 2 in particular. There is real concern about what Stage 3 might be like and whether there might be a government interoperability mandate in it as proposed by JASON. I find the vendor community in favor of an approach in which industry collaborates with other stakeholders. It is entirely possible that long before 2017, when Stage 3 is due, the matter of interoperability will be settled. At least I hope that's the case.
MB: Should that happen, what would the impact be?
JH: I think it will be a springboard for innovation. Developers will have the "universal app platform" envisioned by JASON and will be able to concentrate on functionality rather than complex integration challenges around the various EHR platforms. Moreover, as I know you already know, JSON and REST are familiar and popular technologies. Replacing complex healthcare-specific document and messaging standards with them will make the field more attractive to developers who will bring an outside perspective and new ideas, things we need in health informatics.
Surprisingly to some, I think this will benefit the existing vendors who will have new and important functionality to offer their customers without necessarily having had to invent and develop it. In the end the bar will be raised. EHRs will become more user-friendly and more supportive of the physician's workflow and mental processes. This has the real potential to be good for all stakeholders. That's certainly our goal.
MB: John, one final question. One limitation of Direct is that it only supports "push" -- for example, the sending of a CCD by a referring physician to the specialist who will be seeing the patient. There are numerous use-cases, such as a patient wanting their personal health record to be automatically updated whenever they see a physician, that require "pull" -- initiating the transfer of data from the receiving end. Will FHIR potentially impact that?
JH: As you've said, attaching a CCDA document such as a CCD to a secure Direct email supports only push use cases. Direct will continue to be used until FHIR-based APIs are more common. Since FHIR APIs are read/write, there's no limitation on their use for push as well as pull. So, in time, this is one of the specific reasons why FHIR APIs may well supplant Direct as the means of health information exchange for many, if not most, use-cases.
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