ONC FHIR at Scale Taskforce (FAST) Workshop: An Architectural Framework for Ecosystem Infrastructure

Monday, September 14, 2020; 08:30 AM EDT – 5:00 PM ET
Virtual, online

Join ONC and members of the FHIR at Scale Taskforce (FAST) initiative for a full day workshop titled: “FAST, An Architectural Framework for Ecosystem Infrastructure.” Having developed and proposed solutions to address technical infrastructure challenges associated with deploying FHIR solutions “at scale,” the FAST community now seeks to explore and solicit feedback on the both the architectural considerations and pathways to implementation for each of these solutions.

The FAST Initiative recognizes that ongoing collaboration and coordination with industry leading efforts and a broader group of industry stakeholders is key to understanding industry challenges and successes, ensuring an accurate industry wide gap analysis, maintaining awareness of new developments, and avoiding duplication of efforts. To that end, this workshop will support The FAST Initiative’s goal to maintain transparency and communication, while welcoming industry feedback that can inform our collective efforts and approaches.

For more information on the FAST initiative, please review the following resources:

Workshop Goals:

  • Update community, raise industry awareness and share the FAST progress and solutions (V3 solutions documents draft).
  • Gather industry feedback, engage target future “landing places” and figuring out how to put solutions into practice.
  • Feedback/content to feed into FAST Action Plan (e.g., ‘homes’, deployment considerations, etc.).
  • Present solutions into context – the FAST Ecosystem Architecture.

Breakout Session Approach:

  • Facilitator/moderator to introduce topic/content.
  • FAST panelists to support the facilitated discussion.
  • Industry reaction Panel, not presenting, but responding to questions/debating the FAST identify discussion points.
  • Broader discussion with other attendees/participants via Q & A.



8:30am – 10:00am:

Morning Plenary
- API & FHIR overview
- The FAST Structure and Mission
- The FAST Process
- An Ecosystem Approach: infrastructural use cases and core capabilities to FHIR scalability
- Barriers to FHIR Based Solutions Scalability (or workflows)
- FAST Solutions Summary (v3)

10:10am – 12:00pm:

Morning Breakouts - FAST Architectural Considerations

FAST Solution Interdependencies
Lead Facilitator:
Patrick Murta, Humana

FAST and Trust Framework(s)
Lead Facilitator:
Paul Oates, Cigna

Testing and Certification
Lead Facilitators:
Sandy Vance, AEGIS and Lee Barrett, EHNAC

Stakeholder Nuances
Lead Facilitators:
Stephen Konya, ONC and Lenel James, BCBSA


  1. Confirm that each one of these solutions can be implemented independently.
  2. Explore if there are potential  groupings of solutions to implement simultaneously.
  3. Gather from participants the things that they would rather have sooner.

The ability to locate FHIR endpoints, ensure proper security and identity, and route via intermediaries when most efficient, are key to reliable electronic health information exchange.

Scaling the way we exchange information across the health care ecosystem using FHIR relies on a set of core capabilities with potential interdependencies.

Through a collaborative conversation with industry experts, this session will explore the interdependencies between the FAST proposed solutions, and the architecture of a FHIR ecosystem running at scale.


  1. Consider how “trust frameworks” fit in the model of evolving FHIR-enabled interoperability.
  2. Given the multitude of technical approaches determined or impacted by trust frameworks (HIE-based, or Direct), consider if there are particular challenges and opportunities for trust frameworks in achieving FHIR-enabled interoperability at scale.

FHIR is known for its capability to support integration needed in modern healthcare to achieve integrated care delivery. A key component of running FHIR at scale is predicated on the ability for transactions to cross trust frameworks. An open discussion on how the technical approaches determined by or impacted by trust frameworks fit into this model would be fruitful.
This session will explore the potential of a scalable ecosystem when a trust environment is a dependency for interoperability among stakeholders.

FAST facilitators will dive in and explore how network(s) propose particular technical approaches as part of their trust frameworks, even when it’s still being built, by starting with the following two questions;

1) What are the key technical components of a foundational trust framework and how could multiple networks share a common foundation for trust?

2) Where are we today in building this capability?


  1. Confirm scope of testing & certification proposed solution is appropriate.
  2. Validate if it can be done without undue burden/adding another process step for orgs.
  3. Consider the pros and cons of automated, ongoing certification.
  4. Discuss the potential role of sanctioned bodies in supporting certification.

How do we test and ensure conformance for FHIR based solutions at scale? What is the right level of conformance and how can we test the FAST core capabilities at scale?

By way of an active discussion around the solution proposed by the FAST Testing and Certification team, we would like to explore further what are the current industry needs for scalable FHIR testing and the capabilities to be in place to meet these needs.


  1. Solicit requirements for scaling solutions from organizations other than payers, providers, and consumers (e.g., public health, HIE, quality, research and pharma, etc.).


Stakeholder nuances, and the need to develop functional use cases specific to various affinity groups has led to the establishment of numerous HL7 FHIR accelerators and other collaborative efforts.

FAST Solutions are intended to be designed in a way that they will be repeatable and valuable in any functional use case scenario when deploying FHIR at scale. Therefore, it’s critical that FAST community remains open and inclusive to all stakeholders groups, and frequently provides a forum for anyone to highlight what nuances and special considerations they feel need to be addressed relative to their unique needs/limitations.

This session will serve as such an open forum, where numerous stakeholder groups (public health, payers, providers, HIEs, researchers, etc.) will present concerns they have about FAST solutions be deployed or adopted within their community, with an opportunity  to explore how those challenges can be addressed.

12:00pm – 1:00pm


1:00pm – 2:30pm:

Afternoon Breakouts Part 1 - FAST Pathways to Implementation

Lead Facilitator:
Patrick Murta, Humana

Regulations / Policy
Lead Facilitator:
Robert Dieterle, EnableCare

Lead Facilitator:
Paul Oates, Cigna


  1. Determine which requirements can be part of existing standards vs. the need to create new standards.

This session will explore the possible paths forward for the FAST standards. We will examine the potential for inclusion in existing standards as well as the need to create new standards to support an infrastructure that enables FHIR workflows to scale.
The discussion will take into consideration the short versus long term goals and the timing considerations inherent in extending current standards or developing new standards. We plan to have a dynamic conversation led by the FAST team with contributing input from SDOs and other industry experts. 

We invite all attendees to contribute or ask questions provide feedback in the chat box.


  1. Consider the current regulatory landscape and how it presents opportunities or challenges related to each of the proposed solutions.
  2. Explore policy concepts and considerations that would allow for transparent and predictable  update cycles in response to industry need.
  3. Discuss ways to mitigate impact of understanding and implementing regulatory requirements for smaller organizations.

Along with the technical barriers to FHIR based solution scalability, the FAST Initiative identified a series of regulatory requirements that may present challenges or have implications for FHIR adoption. We will discuss opportunities to mitigate challenges under existing regulation that may impact the utilization of FHIR standards. The participants in this track will review the implications of recent regulations that have mandated the adoption of FHIR.  Finally, we will focus on the opportunity to explore policy concepts and considerations that could facilitate the use of the FHIR based solutions at scale.
Join us for a session where FAST members and an expert reaction panel will discuss the policy and regulatory aspects that could support the FAST ecosystem infrastructure to scale and accelerate the FHIR standard adoption.


  1. Explore process related elements for implementation of FHIR-enabled interoperability at scale (e.g. process related governance, funding, and operational considerations, etc.)
  2. Identify key things necessary to deploy solutions in a sustainable manner.
  3. Explore limitations and opportunities to convene related groups that need to avoid any implication of anti-trust.

Bonus: What’s the ongoing forum across the community – where do we convene related groups that need to avoid any implication of anti-trust?

FAST leadership identified the need for a process component to the FAST solution development and deployment cycle that will support moving the solution from conceptual to implementations.  We will focus on the need for sustainable process to enable the deployment and support the ongoing requirement for the adoption of FHIR at scale. The session will specifically focus on governance, operation and evolution of FHIR infrastructure.
Come and explore with us other potential steps to solution implementation, that will allow the FAST ecosystem infrastructure to support FHIR at scale.

2:30pm – 3:00pm:


3:00pm – 4:00pm:

Afternoon Breakouts Part 2 - FAST Pathways to Implementation

Timing Considerations / Interim Steps
Lead Facilitator:
Paul Oates, Cigna

Lead Facilitators:
Patrick Murta, Humana, and
Yauheni Solad, Yale New Haven Health

Intermediary Discussion
Lead Facilitator:
Robert Dieterle, EnableCare


  1. Capture feedback on interim plans for endpoint directories.
  2. Explore options for interim security solutions above and beyond what already exists – what do we need for 2021?
  3. Capture any concerns regarding recommended metadata approach.
  4. Discuss implementation planning and timelines to prepare for Testing & Certification (above and beyond HL7 tooling, and what’s available in the industry to use voluntarily).

Implementation or deployment for some of the FAST proposed solutions may take longer than (in some cases), is needed based on the federal laws and regulations requirements (i.e. the ONC and CMS Final Interoperability Rules under the 21st Century Cures Act).

This breakout session aims to highlight timing considerations associated with the FAST solutions and explore what interim steps and solutions can be pursued to address the gaps between mandates, solution deployment timelines and industry readiness.


  1. Explain and reiterate what we are seeking to pilot from a FAST perspective (test FAST core capabilities with Da Vinci use cases initially provided as the workflow).
  2. Discuss if the model of using Da Vinci use cases makes sense:
    1. Solicit feedback on the technical approach using Da Vinci use cases.
    2. Explore benefits of initially using Da Vinci.
    3. Verify the assumption that the best way to solve a problem is to leverage trust that already exists.
  3. Explore interest for potential future pilots’ partners.

As the industry is building functional capabilities to support real-time information exchange, in a variety of FHIR workflows (i.e. to address clinical care, clinical data integration, etc.), FAST is working on the technical infrastructural aspects that would support these workflows be run at scale.

Demonstrations to test the Da Vinci functional capabilities have been successfully tested over the last several years. However, testing and validating how the FAST solutions will impact/improve the deployment of those functional solutions at scale is still a process that needs to be established.

Building on the variety of functional aspects that would benefit from a scalability infrastructure, the FAST Pilots team along with an industry expert reaction panel will explore how it is best align the industry needs, with the existent capabilities and the potential of a scaling infrastructure, in a pilot testing environment. 


  1. Identify intermediary requirements for RESTful FHIR exchanges.
  2. Identify intermediary- intermediary exchange requirements.
  3. Define service level required for intermediaries to meet (1) and (2).

A scalable ecosystem infrastructure requires standards, process, and regulation to be addressed and aligned. By working collaboratively with industry solutions that currently exist or are in development, FAST can leverage these building blocks to make more rapid progress towards the final goal of supporting the industry need for a scalable architecture for FHIR based exchanges.

This session will focus on the current state of intermediary support of RESTful FHIR exchanges, scalability of the solutions, and the need for industry wide coordination.  We will specifically focus on any intermediary – intermediary issues that would impact the ability to provide the same real-time services that are available in direct connections between exchange partners. 

We are anticipating a lively discussion on the role of intermediaries in supporting scalability of FHIR based solutions.

4:00pm – 4:15pm:


4:15pm – 5:00pm:

Closing Plenary
- Key Takeaways from morning and afternoon breakouts
- The FAST Action Plan
- Immediate next steps
- Closing remarks