FHIR Implementation Quality: Preventing the Great Escape

“Escaped Defects” are defects that are discovered in production.

Wow. Let that sink in for a moment.

This is healthcare we’re talking about; people’s lives are on the line. Although the certainty of catastrophe is not the same as with a faulty space shuttle O-ring, the potential for patient tragedy is the payload of each escaped defect.

As a FHIR  implementation community, are we really OK with defects slipping through our development and QA processes and into patient-risking production?

“Best Practice” Metrics: Irony as High Art

According to some agile development tooling vendors, tracking escaped defects is a “best practice” of agile practitioners. Wait! Tracking escaped defects? How about eliminating them?

On one hand, preventing escaped defects should be a top priority, so we need to know if they happen. On the other hand, that they are a “core Agile quality metric” implies surrender to their inevitability. Let’s be better than that as we implement FHIR.

This is healthcare we’re talking about. Perfection may not be possible all the time, but quality matters A LOT.

Clearly, we need to raise this bar when implementing healthcare solutions.

The Promise of The Three Amigos

A core idea of the agile development process (which nearly all implementation teams follow to some degree) is increased quality via rapid iterations to deliver bite-sized functionality, driven by close collaboration between the business stakeholder (“product owner”), developers, and quality assurance (QA) (the “Three Amogos”).

Each of those small functionality chunks is described in small requirements documents called user stories. Each user story is co-approved (ideally co-authored) by the “three amigos:” the product owner, the developer, and the tester (QA).

That approval process goes something like this:

  • Product owner: “If you implement the functionality as described in this user story and the tester confirms that it works as described, I will accept the functionality.”
  • Developer: “I agree that this user story is written with enough clarity that I can implement it without ambiguity.” 
  • Tester: “I know exactly how to test this.”

The promise of the Three Amigos alignment gives everyone goosebumps of anticipation, and this promise is realized by high-functioning implementation teams. Some teams produce defect-free functionality with few iterations; others iterate more, efficiently discovering and resolving defects until they have a (usually) defect-free release candidate.

However, many teams aren’t as lucky. Release deadlines cut short iteration opportunities, or the next feature seems more interesting and urgent to stakeholders than iterating on the last.

The reality of being human gets in the way of following best practices. Defects go undetected, and they escape into production.

Enter the Fourth Amigo

Even the most effective teams miss things; apparently, enough teams miss defects that the agile tool vendors track escaped defects as a “key metric.

But what if each team had a fourth member (their “Fourth Amigo”)—let’s call them “Been There; Done That (BTDT)”—who already knows where all the sneaky FHIR implementation defects are likely to appear? BTDT lives and breathes FHIR specifications and IGs; it knows all the nuances of how FHIR APIs should work, and it has mapped the landscape of the ways FHIR implementations can fall short.

That Fourth Amigo BTDT has seen it all, so it uses rigorous and precise validation algorithms to trap the most pernicious and subtle defects. Being a great team member, BDTD shares its intelligence with all stakeholders in real-time, empowering everyone–developers, testers, managers and senior executives–with objective measurements of FHIR implementation quality and detailed information about how to fix each defect.

The Fourth Amigo is obsessed with eliminating escaped defects–and is really good at it.

Touchstone: Your Fourth Amigo

The AEGIS team has been obsessed with interoperability implementation quality since FAXes were considered state-of-the-art. When the idea of FHIR was first conceived and gaining support, we immediately saw its promise for accelerating interoperability, so we have been contributors to core FHIR specifications and several IGs ever since. We are contributing authors to the FHIR Testing paradigm and of the TestScript FHIR resource. We have invested millions of our own money in developing and maturing Touchstone, our FHIR conformance platform that is the foundation of our FHIR implementation and integrated ecosystem. 

Touchstone is your data quality dividend earned from our investment. With thousands of FHIR TestScripts and almost 5 million FHIR messages exchanged, Touchstone has detected thousands of FHIR implementation defects for savvy implementation teams throughout the world.

Touchstone is your data quality dividend on our investment in FHIR implementation safety.

Take a quick tour and take Touchstone for a spin at https://touchstone.com/tour. Priced at a fraction of the price of a team member, Touchstone is your Fourth Amigo.

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