Datica Podcast

June 11, 2019

A Conversation with the Father of FHIR

In this episode of 4x4 Health, we talk to Grahame Grieve, the architect-developer of HL7s Fast Healthcare Interoperability Resources (FHIR) and principle at Health Intersections of Melbourne, Australia.  Grahame is one of the world’s foremost experts on healthcare interoperability, a strong leader of the Health IT community, and is sometimes referred to as the ‘Father of FHIR.’ “[Interoperability] is not a technology problem . . . It’s an information and people problem”, Grahame observes before describing how FHIR was able to break through this ‘people problem’ by using a collaborative and community driven approach. Grahame’s passion for improving healthcare outcomes with technologies like FHIR shines throughout the episode. We think you will leave this episode inspired and optimistic about an interoperable future for healthcare.


Dr. Dave Levin: Welcome to 4 x 4 Health, sponsored by Sansoro Health. Sansoro Health, integration at the speed of innovation. Check them out at www.sansorohealth.com. Today I’m talking with Graham Grieve, Principal with Health Intersections of Melbourne, Australia and Architect Developer of HL7’s Fast Healthcare Interoperability Resources or FHIR, the specification that’s playing increasingly important role in the exchange of health information. Graham specializes in interoperability, one of the hottest topics in Health IT and for that matter, all of Healthcare IT. His approaches balance clinical, management and business perspectives with deep technical knowledge and strong leadership skills. He’s recognized as an international leader in the field who’s referred to by some as the Father of Five. Graham emphasizes the role that community plays in bringing about successful change, especially when developing useful standards. This holistic approach has led to remarkable early success and rapid adoption of FHIR. In addition to his work on international standards, Graham advises a wide variety of organizations on product development, clinical safety, integration, architecture and standards implementation in development. When he’s not traveling the world, Graham lives in Melbourne, Australia with his wife and two daughters. Graham plays the piano and the Didgeridoo and occasionally gets to go kayak fishing. Maybe we can get him to send a few recordings of him playing the Didgeridoo to put on our website. Now, before we get started, I have to deal with the issue of FHIR puns. Regular listeners know that we have a strict no FHIR puns policy on 4 x 4 Health. We’ve even occasionally had to call out the pun patrol to issue citations. Now, I have no idea how Graham feels about this subject, we haven’t discussed it. But given his essential role in the creation of FHIR, we’re suspending enforcement today and leaving it up to his judgment to pun or not. So, with that bit of business out of the way, welcome to a 4 x 4 Health, Graham.

Graham Grieve: Thanks very much. Pleasure to be here.

Dr. Dave Levin: Let’s jump right in. I’m going to ask you a series of four questions and we’ll take about four minutes to discuss each one. So, to get us started, tell us a bit about yourself and your organization.

Graham Grieve: So, I started life as a farmer in New Zealand. I thought I was going to do plant breeding research, so I often did Biochemistry University. Then I did a grand New Zealand thing and came to Australia for a holiday. I ran out of money and had to get a job. I was in Melbourne, I got a job, I got a house, I got a family, I’m still here. The job happened to be in a hospital lab. Within a week of study in the hospital lab I knew that I was going to be in healthcare the rest of my life. I worked in the lab; I did a bunch of IT work in the lab. I then did a PhD, although I never finished it. Then I went and worked for a lab system stand up and got more and more involved in interoperability, in HL7. Then I went freelancing, contracting, consulting and I realized early on in that process that really the standards we had in healthcare had been lifted a long way behind the rest of the world. And so, I said, okay, what would it look like if we took the lightest and brightest approach and used it for health? And so that turned into FHIR and it took off like a rocket. Notice I think I, [Unclear]. And, here I am trying to keep ahead of the on running ocean that’s trying to, you know, swallow us up. And it’s been an incredible journey that so far exceeded my hopes and aspirations and my worst fears same time and I’m just really gratified that we have such an active community that is changing the world and I’m a bit embarrassed that I get so much intention when it’s really such a place of community works, so many hundreds of individuals contribute to what we have, and so, I’m just really lucky. You said, you know, my organization, my organization, while I’m a freelancer, well, works for HL7 which you know, is a Standards Development Organization and a community convener, and then I have the FHIR community which is the best well defined but even more active and passionate group of people who really want to change healthcare and I’m just so thrilled to have those people onboard and I’m just hanging on and enjoying the ride.

Dr. Dave Levin: Well, that was a great initial overview and we’re definitely going to get a little deeper into the work and FHIR and the role of community and the rest of that. One of the themes I really like to explore in this podcast is folks that have come from outside of healthcare or the reasons that folks chose healthcare. You said something very intriguing, you said, within a week of working in the lab, you’d knew. Tell us a little bit more about that.

Graham Grieve: When it was a faith-based thing, but I realized once I was working in the healthcare that it was bigger than a job, it was more than just money. There was a mission here. There’s lives to be saved, there’s people’s lives that make better. And that growing strongly might affect me and my own experiences have taught me that money’s a lot less important than health and happiness and I’m so thrilled to be part of an industry that thinks that way and has always done so. And it’s my pleasure to have so many people around me who see life the same way. And that is why I’ve always felt as though I will always work in healthcare and I’ve passed it onto my oldest daughter who’s now doing Chemistry at University with a strong focus on Medical Applications because she’s got that same bug to make the life better for people.

Dr. Dave Levin: Well, as you might imagine, a lot of us share that, that this idea of a mission that really matters. And the thing that I’ve always tried to point out to my colleagues is everyone involved shares in that mission. Whether you’re on the front lines providing clinical care or you’re building the systems or the facilities that enable that right on down up to and including the folks who clean up and make sure that the place is operational and like you, I take great joy in that and it’s sustained me through decades of ups and downs in healthcare. So, thank you for sharing that.

Graham Grieve: Pleasure and it can be a tough gig to be in this as well. It makes demands of you that wouldn’t otherwise be made and that’s part actually, the best part of why I like it.

Dr. Dave Levin: I couldn’t agree more. There’s a lot of easier things to do in life and probably a lot of easier ways to make money too if that’s what you’re really about. So, it sounds like you and I are much aligned on that.

Graham Grieve: Yeah.

Dr. Dave Levin: Let’s turn to FHIR for a few moments and we’ll start with some technical stuff but I, this idea of community I think is also really important and we’ll come back to that. But for a general audience, give us a quick definition of what FHIR is and what you and the FHIR community hope to accomplish with this approach?

Graham Grieve: So, FHIR is a set of rules on how data is exchanged between systems. There’s a focus on APIs, although we have otherwise to exchange data. But it describes the kind of data that you can exchange, when you might exchange it and how you can exchange it. And by describing those things, we create the set of capabilities that allow applications that support humans providing healthcare to get the right information in the right place at the right time and to add value to that process and to allow humans to coordinate their process better. The drive in a specification in the community is very technical. How do you do things? But it’s absolutely about why do you do those things and what impact does it make? And our goal is to change the way healthcare has provided by enabling humans to leverage computers more effectively. IT never solves problems but IT can get in the way of humans solving problems. We’re about enabling clinical champions to say, I want to make practice better, I want to make lives better, I want to change the game and that’s so, we are definitely chasing after clinical change and that has become relevant now that we’ve built enough infrastructure but we did that by making it possible to do things that people want to do through better use of information.

Dr. Dave Levin: Yeah, I might, I think that’s a really good summary and my own view is that, our hope was that when we rolled out electronic health records that we would solve some of these problems, that the data would be less fragmented, that it would follow patients to wherever they went for care. And I think the reality is we achieved some of that but not enough. And, in some ways, we created new, very important silos for data but silos nevertheless. And in some ways, I think it is highlighted the importance of interoperability, the ability to exchange data and the role that, that’s playing in either inhibiting or enabling better care and better solutions, real innovation in healthcare. My guess is you would probably agree with a lot of that. But we do have another rule of 4 x 4 Health which is please call BS on the host and feel free to do so.

Graham Grieve: No, I mean, I completely agree and what I’m hearing is that they’ve able to put in a lot of effort into gathering the information but they’re not feeling as if it’s worth it because it’s not able to be leveraged at the right place at the right time. And so, the right limiting step is very much interoperability and the challenges around that. And so, yeah, when I started working on FHIR, I was really simple. I’m saying, the web has transformed other industries. The web as it a set of ways of thinking and technologies and ways to build community is really powerful. Let’s unleash that in healthcare. I’ve been doing that really clever. I’m just committing to it and said, let’s, I’m going to do this and come and join me and people did. And it’s about bringing that change to, and acquiring it at the place that turns out to be the right limiting step. And across the whole world, people are in all sorts of different points in the journey about adopting clinical record, keeping software to some degree or other but everybody’s stuck onto interoperability.

Dr. Dave Levin: Yeah, and the other thing I really like about this approach is it’s really focused on practical outcomes. This was not an academic exercise that ends up sitting on a shelf somewhere but really focused on solving real world problems. Give us some examples of what you’re seeing right now of the practical application of the FHIR standard, who’s using it now and what are you seeing as benefits from that?

Graham Grieve: So, I mean for, I usually come in on the academic thing. What we do is deeply informed by academic rigor and thinking but it’s matched by, to quote from an earlier stat, earlier podcast was, it’s matched by street cred and we have that street cred because we actually said, let’s try this stuff in practice as well. So, where are some things that people are using it? So, obviously the most, you know, hottest profile usage is the Patient Portal API that Argonaut community worked up. And so, it’s great to see that patient empowerment, patient agenda because I believe in that passionately. We have, you know, a lot of really active work now in improving the workflow between the provider and the payer in the Davinci project and that’s about to come online. Looking wider, I feel there’s a huge amount of work around gathering data, using FHIR’s interoperability layer to power, big data, data researching, AI, and the, bringing that, the lessons from that to bear in practice into the, you know, healthcare process. So, data analytics and decision support, there’s plenty of, it’s just clinical process work within vendors that’s not getting all of profile outside them but they’re saying, we can, you know, I, seamless clinical process across the different parts of their software using, you know, FHIR and so for me, nations building national clinical repositories or specific focus disease repository is based on the specification. And to me the great thing is it’s stable to help and solve all of those problems and my goal is, no matter how you want to improve healthcare, we believe that we want to be relevant in exchanging that information and useful to you to do that.

Dr. Dave Levin: That’s a really good response and I want to be clear if I didn’t intend to demean academic research in any way. The point being that, you know, the ability to take that evidence, science, you know, academic learnings and apply that in practical ways that really make a difference in the real world is a real art, I think and something I really admire and I think you described that well. Where do you see this going, what’s coming next, how do you see the standard evolving, how do you see adoption playing out in the coming months and years?

Graham Grieve: So, the standard is mature and now, it’s moved from, you know, initially I said, what is it look like to have an agile standard? And so, we had a very agile standard and that was, you know, led to the process where we have the connected thumb driven development. But every time it became clear that, that’s really great way to initialize in initiated community. But over time you become more sensitive to the need for stability and you actually need change list because so many people have invested in what we’re doing. And in fact, this is sociology, it’s not technology. And my following Tuckman’s stages of group development, storming, forming, forming, storming, norming. We’re getting towards the norming phase now and we still have other parts of the, some parts of the specification are very early. In the storming phase, we’re adding support for evidence-based medicine which no one’s ever made computable and interoperable before. So, that would be really interesting process. Whereas the stuff that’s stable is, you know, really starting to get quite stable and make it normative and which means, you know, we make it, we don’t change it without considerable procedural challenge. But my view has been that, the way it kind of build a trillion-dollar ecosystem on top of FHIR. That’s about the amount of money that people will spend in the spice controlled by FHIR. They’re not going to spend it on FHIR, they’re going to spend it on projects that use FHIR. It might be a trillion dollars worldwide and you’re going to have a trillion dollars’ worth of governance and stability. So, what we have is the process that migrates that and we’re starting to get that maturity now and now we’re saying, how do we support the process of making use of it, leave reaching it, supporting vendors that are rolling it out, reaching out to new communities that we haven’t interacted with before, like for instance, HIMS and HL7. They’ve always kind of been parallel universes but now we’re saying to HIM, HIMS is saying, we’ll be talking ins and saying, what does it look like to start really influencing Healthcare IT practice through deployment of interoperability? What can we learn, what can we pass on, how do we do community in that new space? And I think that’s in the short term. In the longer term, I always said we had three goals. The first is to disrupt Healthcare IT standards and that’s pretty much bagged. They even the standards that are not FHIR, are all busy trying to figure out how to, you know, have a process like what we have because it works, because we’re building community as we’ve hammered away on. Then we set out to change Healthcare IT and that’s a process that’s obvious and happening. It’s not complete by any stretch of the imagination. But then I said, and we want to change health and that for me, that’s where their focus is starting to be more. Now that it’s time for us to say, how do we change healthcare and healthcare outcomes, not just Healthcare IT. And that’s a, that’s an ongoing discussion that needs another new set of communities to be built and that’s where we are starting to turn our attention to now, how do we leverage Healthcare IT and the healthcare outcomes and even things that are in coordinated care, continuity of the care, managed care plans and said ongoing process.

Dr. Dave Levin: The thing that I find particularly fascinating and impressive about this work, and there’s a lot to admire in it, is the thought that’s been put into the change management aspects of this. And you said, we’re hammering this issue of community but I think too often we embark on trying to implement change in healthcare and we really haven’t thought through. What exactly is the model for change, what’s our theory of how we’re going to affect change? We get really excited about the details of the work and perhaps the technical aspects of the work or in a quality improvement program. Maybe we are really focused on, what does the evidence tell us and the gaps and approaches which is all really valuable but we don’t seem to spend as much time thinking about the human aspects of this and, you know, how do we actually affect real change in the world? And I just find it so striking that what outsiders might look at and go, well, this is just a technical exercise. How much emphasis you place on that and at the risk of beating it further to death. Share with us a little more about, you know, your views on this and how it’s played out across the FHIR community.

Graham Grieve: Well, this is my reign, you know. I wonder if I, three rules of interoperability and one that really drives it. Since that interoperability is not a technology problem, interoperability is a people problem. It was a long time ago since we had a technology problem and we’d all be better off if we stepped, stopped talking about IT. We don’t have an IT problem; we have an information management and a people problem. And so, where you catch on from the start, this is not a technology project, this is a people project. And so, that’s why I always will hammer community because we are fundamentally a people project. That health is a people-based business, it changes the people-based process. And so, we said, the most important thing we can do is build a community and banish through that and then everything that we do manifests through people. And so, we’d just hammer around on this point internally and externally. And when we say, how are we going? We don’t, we don’t actually worry about how the standards going. When I sit down with a team and we go around the table strengths and weaknesses, when I’m talking about the spec way, I’m talking about the community because that is the most important thing that we have and that we contribute our culture and our existence and the wild passion that drives the community to engage all over the place. It’s that engagement that generates the noise that gets people to say, oh, what is it you’re actually doing? And then they come on and they’re like, can you just like leave us alone, don’t make us change? We’re happy with where they are. So, there’s this kind of initial resistance always happens and then they look at what actually doing and they go, ah, oh, that’s cool. And then they’re on board and that, you know, we’ve seen, it’s like you throw a stone into a pond and you’re watching the ripples spreading out and we’re seeing them stretch more further and further away from the core of interop and further into health. And you know, our goal is, how to change health outcomes in the end? That’s in the end from that comes back to people. So, this is it something you’re happy to rant about, I’m very passionate about but it’s not a technology problem where we have to stop thinking of it as a technology problem. It’s an information and people problem.

Dr. Dave Levin: Well, I’m glad you went right to your rant. I didn’t, ask you that question yet but it was perfect. And also, I usually have to warn my guests to keep it PG-13 which, you know we try to be family friendly but you did that beautifully as well. I frankly don’t think it’s much of a rant, I think you’re spot on and to my point earlier, I think regardless of what you’re doing, whether it’s in healthcare or at home or self-improvement, the principles are the same. And you chose the word engagement earlier which is a real hot button word for me. I define it in this setting as communication plus governance.

Graham Grieve: That community, the rant that it is, you know, we’ve got a national health record system here in Australia. It’s really limited in functionality because it was based on political compromises to how we could even build a national identify, a national healthcare system. Fine! That was, we knew it was going to be limited because of political reality, but what happened is we’ve, we’re trying to get to the point where we can have an open discussion about the real problems, around clinical trust, clinical engagement, clinical governance, clinical commitment to shared record keeping or seamless data exchange which is a two way obligation but the doctors have walked away from it thinking that’s a technology problem and a technology failure. And that’s my real issue is clinicians keep thinking that fixing clinical practice is a technology problem. That’s not a rant, it’s not a technology problem. You have to think about how to share a common clinical practice and then you have to think about how to have clinical, bi-directional clinical obligations around data exchange and patient exchange. It’s not, you kind of stopped saying technology is going to solve the problem. Technology will automate whatever your solution to the problem is and if your solution to the problem isn’t going to work, the technology will automate the work not working this of it. That’s fine for the writers, no problem.

Dr. Dave Levin: I think that’s really well said and as I was thinking about, you’re talking about this perspective and for better or worse, I’ve been deep into the proposed rules from the Office of National Coordinator in United States and the Centers for Medicaid and Medicare and I think it reflects exactly what you’re saying here. Yes, there are technical aspects to the proposed rules. Those are relatively straightforward and I would think very pleasing to you and an endorsement of the work with the FHIR community, since it says pretty bluntly, we’re all going to adopt and use a FHIR standard and we’re going to use that to deliver a defined core set of data. What’s been much more interesting to me, fascinating to me about these rules is the other aspects, that the, what I refer to as the behavioral aspects or the people part as you call it which really get into information blocking and noncompetitive practices, anti-competitive practices, things like that. That I agree with you 100%, a far more responsible for the barriers that exist today than any technical issues.

Graham Grieve: Actually, I have to come in a couple of things on what you said there. First of all is, I wouldn’t say, have been tremendous supporters of as both conceptually and financially and I have to acknowledge Don Rucker’s support in particular. It’s really critical to contribute to our ability to deal with that technical debt and I really appreciate that. And I want to say about ONC is you really under appreciate how wonderful it is to have political leaders who truly understand the problem, truly understand interoperability and healthcare and clinical process. When I visit countries, political leaders in the rest of the world, they have no idea. They really, really don’t have any idea. And I hear a lot of frustration with the governance process in the United States but from where I sit, try better than elsewhere. I understand the frustration and you know, there’s my, we’re all here, we’re dealing with a series of compromises at crest, multiple different levels. Every compromise you make will, you know, at least some people as the, holding the bag. But we are going in the FHIR community as well, it’s not perfect. It’s a way of making a series of compromises that leaves enough people committed to the community. And that’s I think how people need to look at the work of the ONC and the CMS and so forth is, you know, nothing is perfect, political processes deeply compromised, how do we make the best out of what we’ve got and it seems to me that things could be worse.

Dr. Dave Levin: Well, you and I very much share that view and I’m publicly on record as praising ONC for the work that they’ve been doing. It’s not, it’s a very popular pastime in the United States to bash our Federal Government and a lot of times it’s deserved. But I think this is a real exception here. I think they’ve done good work. They’re good people, they’re well intended and I’ve also found them to be particularly accessible and interested in the public’s input. And so, I share that view with you. I think your overall summary is spot on.

Graham Grieve: And don’t worry! Bashing the government is a natural human pastime in every country I’ve been to, even by the Government itself.

Dr. Dave Levin: That’s right indeed. If you’ve just joined us, you’re listening to 4x4 Health and we’re talking with Graham Grieve, Principal with Health Intersections and Architect Developer of HL7, FHIR. I want to give you a chance to continue any additional rants. Is there anything else you want to add; any pet peeves you want to get on the record Graham before we turn to other topics?

Graham Grieve: Now look, I’ve done my big peeve about technology, information and people. I guess if there was another thing that in HL7, we engage with about a thousand vendors, they all understand the standards game, why we have standards, how it influences their work, how they influence the standards process and what it achieves. But a lot of people assume that means that we just have seamless information exchange but as long as institutions buy highly configurable systems and then spend hundreds of billions of dollars configuring those systems, they’re next hundreds of billions of dollars of worth of non-interoperability and we can’t change that. If people come to us and say, can you just make a rule that we can have consistent information, that would mean by the way we work with building community rather than imposing top down fantasies that we would have to engage with a 100,000 institutions that don’t even know why we’re bothering to do that. And so, it’s this cultural change to say, that standardization process matters. So, when I expect the outcome of what we’re doing will be, that in 10 years’ time people will be saying, that FHIR standard is so short, is full of shortcomings because now, we’re ready to actually hard code those agreements, because people have actually said, you know what, that’s holding us back. Let’s all come to agreement. And then now they like 10 years later going, but the FHIR could standard doesn’t reflect those agreements because we finally made them. And so, a standards process is inherently self limiting. You get to the top of the mountain and set out to climb and you’ve run out of energy, and you’ve run out of freedom, and it’s time for some other mountain but man, we have made that other projects problem so big by the sheer size of the community persist that we’ve built. How much energy it’s going to the take to do it again, really scary. So, we’ve just got to make the best of what we can now and hope that we last as long as we can, that’s best. You know, my goal is always when I say the community is with developing for technology, eventually we’re going to run out of steam, we’re going to have that, you know, dreaded, gotten a trough of despair. Let’s just make sure the fundamentals are in place as much as possible, both in the community and the technology. And the better the fundamentals are, the more prepared will be when those hard times come.

Dr. Dave Levin: Well, I really admire that. I mean, I think it’s a, that’s a great blend of humility and vision and I sort of view it the same way. I think most the progress is we take a few steps forward and then maybe a step back and maybe we go sideways a little and then we regroup and we take a few more steps forward and, but over time incrementally, directionally things are good. So, I really appreciate and you’re sort of given me an opening to ask another question and you and I’ve never discussed this, so I can’t wait to see where this goes. But how do you view the sort of interplay between standards and custom and proprietary work? How do they fit together or do they fit together?

Graham Grieve: Yeah, they absolutely do. The first part is, the whole point of standardizing something is to allow for innovation to be built on top of it. And so, this is real art form around what do you standardize and what do you leave because you can end up standardizing exactly what people need to innovate in and then you just killing everything, or you can standardize some infrastructure and create an explosion of innovation on top of that. And so, this is real. I’d form around, what is it that you standardize and what do you not? And then this is also this process interchange between do you, you know, you can only standardize after some, at least some form of in, you know, production, implementation is shown benefit and shown outcomes. And say, you need to innovate; you can’t innovate that much in the community. You standardize what’s been innovated. And so, there’s this process, you know, stepwise process between standards and innovation. And I actually often show in my presentations, I show a picture of a slinky dog in, when I’m talking about this. You know, the front in the end but I can go on different directions for a while but eventually they’re going to snap back together and it’s going to be painful if you stretch it too far. And so, it’s really an art form of keeping those two things working together to get the best outcome in the end. But that’s how I look at that question.

Dr. Dave Levin: Well boy, I really liked the slinky dog analogy. I think I may have to appropriate that for future use. Wayne Cubic and I’ve had this discussion and Wayne is the Chief Technology Officer for HL7 as you of course know. And what the way I drew it was as a Yin and a Yang that they’re sort of closely intertwined. And, my argument was, look, where the standards exist in their robust, we should use those. It provides great advantage but there’s also this kind of voyage of discovery. And so, we want people out on the bleeding edge, experimenting, doing custom work that, that can inform the development of standards in potentially two ways. So, one is, it’s a kind of signal of what’s the market think is important right now. And the second is, it may provide insights into actually executing that, the details of developing a standardized version. And Wayne and I, we agreed on that as a model. His push back was, yeah, but I want that standards part to grow bigger and bigger over time and the custom part to be a smaller part of the Yin and Yang. And, I have to say, I agree, I think that could be valuable as well. But at the end of the day, I think your slinky dog analogy may be a more powerful one, more fitting than the Yin and the Yang.

Graham Grieve: Yeah, yeah. I listened to your exchange with Brian about data. Brian of course in HL7 is my boss. And I thought that you didn’t cover was that the relationship between standards and pairing innovation at a different level. And I think that’s really critical. Being, writing a standard, it’s like, starting a startup, 90% of them fail. You don’t set out to have a failing startup or assigning standard but you often do and I’ve put a lot of time into figuring out why standards failed or not. When I, before I started FHIR and part was the necessity to have community and it can be driven by that. And so, I turned the persons inside that. Nearly part of it was just doing improve my chances of success. But it’s really, you know, a lot of the FHIR process is just an experimental process of finding out of the balance between what we should or shouldn’t standardize.

Dr. Dave Levin: I think that’s really interesting. Elaborate on what you mean about the standardization enabling innovation.

Graham Grieve: Well, so let’s talk about as an example. Well, I mean it’s a whole side of using APIs, right? If I say to everybody, to 25 hospitals, having an API is a great idea. Go off and build an API. 25 hospitals, go off and build an API and then I say a bunch of companies, you can build apps against the APIs in the company’s site, right? 25 different APIs, all looking totally different. We can innovate, I guess. Now, you said of this for 25 hospitals, here’s the API, common API. We all do the same API and they’re like, hey, we can’t innovate without APIs. Yes right, you can’t innovate with the APIs. But when you go to those other companies and say, here’s APIs going away, they go, hey, they all the same. Do you know how much bigger the market is? And that the economics of scale enable innovation at the other level. And it’s the same, you know, like when, I live in Australia, when we first started building railway lines, you know what happened? Every state, every region chose a different route and gauge. That was a nightmare. Eventually, the Government said, it’s too hard and actually paid to impose a single rally gauge on the entire country. But that created a national training system where that was actually supported by National Railway System. And that was innovation that was built on top of the standard rail gauge. And, but if I turned around and said, okay, here’s the standard for clinical, for information about allergies, everybody in the world is going to record exactly this same allergy information. Is that going to help or hinder innovation, right? You can see that it could help innovation and you can also see that will hinder innovation, which isn’t. The only way we know, obviously try it and find out. And so, the FHIR process is really about discovery of the answer to that question. Where should we standardize and what should we know?

Dr. Dave Levin: Well, I just, I really admire the philosophy behind this and I think you’re right and I think we’re beginning to see the fruits of this already. And again, at the end of the day, I think your insight that a lot of this is art and you have to experiment and you may have hypothesis but you’ve got to experiment and go prove that out in the real world. And again, it’s what’s been so fascinating to me about reading about this work and listening to you today is this philosophy on this approach. And boy, it’s hard to argue with the success that it’s achieved so far.

Graham Grieve: Well, yeah, I mean, I feel blessed that so many people have jumped on and said, that set of compromises and philosophy is something that we could commit to and build empires on. And I very much hope that we can hold two echoes and justify that faith.

Dr. Dave Levin: Well, you’ve offered a lot of sage advice here today. As our final question, let me ask you for a formally, what is your most sage advice for us?

Graham Grieve: You know, I’m going to do something really personal. I believe that everyone of us should spend some of our time committing to something greater than we are. Giving to some community organization that’s building civic assets and not only do I believe that we should each do that and I encourage everybody to do that and to join some organization, whether it’s FHIR or a derivative organization of FHIR, working and how to build something you never liked it’s space or whether it’s your local, you know, sports club, I believe that every who are employer says to the employees, I’m going to give you a little bit of your time to give to something greater than the employer. That builds, not employees but committed what, you know, people who are really committed to your vision because you’re giving them time to do that giving. And so, I was encouraged employers to let their employees give to something greater. And that’s my sage advice.

Dr. Dave Levin: Well, it’s truly sage and I couldn’t agree more, in my own experience in and observing others. When we go do that, when we commit to something larger than ourselves, when we give back, it’s also, it’s a great remedy for cynicism, for frustration, for self-pity, you know, and we’re all subject to those things, we’re human. I find it to be incredibly regenerative. And so, in addition to being something that’s good for the community, I think it’s really good for us as individuals as well. So, truly sage advice and good advice for life, not just for work.

Graham Grieve: Nice.

Dr. Dave Levin: We’ve been talking with Graham Grieve, Principal with Health Intersections and Architect Developer of HL7, FHIR. Graham, thanks so much for joining us today.

Graham Grieve: It’s been a pleasure and I didn’t even get any FHIR puns in.

Dr. Dave Levin: Well, like I said, you were totally on your own. We left it to your discretion today, [Laughing]. So, the restrictions will be back in place after this episode.

Graham Grieve: Good, I’m glad.

Dr. Dave Levin: You’ve been listening to 4 x 4 Health, sponsored by Sansoro Health. Sansoro Health, integration at the speed of innovation. Check them out at www.sansorohealth.com. I hope you’ll join us next time for another 4 x 4 discussion with healthcare innovators. Until then, I’m your host Dr. Dave Levin, thanks for listening.