There seems to be agreement that a data-centric rather than a document-centric approach to interoperability is the way forward. But no one really knows what is going to happen when the technological capabilities of open application programming interfaces (APIs) and FHIR (Fast Healthcare Interoperability Resources) profiles run up against the business models of EHR vendors and health systems. Who will want to share patient data with startups developing apps that may threaten to make obsolete part of their EHR system? How many are eager to incorporate patient-generated data into their health records? It is bound to be a messy evolutionary process. But I can tell you that from listening to several presentations at the eHealth Initiative Annual Conference in Washington, D.C., this week that many CIOs are supportive of the public API approach and are starting to see their health system IT environment as more of an open ecosystem that could take advantage of web services and less of a walled garden where they own and control everything.
Neal Sanger, CIO of the Mayo Clinic Health System, talked about re-thinking Mayo’s system architecture based on the realization that it is not going to build everything itself. “How do we connect up pieces of an ecosystem? We are establishing what that looks like,” he said. He described a joint venture with a Silicon Valley firm on a subscription-based model called Better Health (www.getbetter.com) that directs consumers to a personal health assistant and gives them access to Mayo clinic nurses. He also described the work Mayo has done to make sure data from its patient portal can be pushed easily to Apple’s Health Kit. (So far, Sanger said, the feed is only one-way, and Mayo is considering how it would receive data in the other direction from individual’s Apple accounts or from remote monitoring devices.)
Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, said it is not yet clear what will happen in an API-based healthcare economy, because an industry maturation process has to take place. “We saw with Direct what happens when you throw something top-down on the market when no ecosystem already exists. It is just now getting traction. That’s not anyone’s fault. It just takes time to develop,” he said. “And it will take time to develop with APIs and that is a good thing.” He said open APIs are not a nirvana in any vertical market. For instance, Apple has open APIs, but developers still have to go through a vetting process and contractual relationship with Apple before they can put an app in its App Store. (Tripathi is leading the Argonaut Project, which involves leading EHR vendors and health systems eager for FHIR to become a standard quickly. They came together to fund the standards development work at HL7.)
Many CIOs are eager for the API approach to work because they are so frustrated with how costly and slow interface development has been. Joel Vengco, vice president and CIO of five-hospital Baystate Health in western Massachusetts, stunned many participants by describing the “tax” many EHR vendors put on every HIE transaction a physician office does, above and beyond fees for creating interfaces.
After describing the many challenges his organization faces trying to link the 65 different EHRs in use by physicians in his organization in support of population health efforts, Forest Blanton, CIO of six-hospital Memorial Healthcare in Florida, said he strongly supports open and public APIs. He says FHIR standards should be market-driven but facilitated by key government drivers. “This should include clinical data exchange and the ability to pull data for analysis across disparate systems,” he said, “as well as the standardization of nomenclature so organizations would have the capability to push out alerts about gaps in care across disparate systems.”
Baystate’s Vengco, who was previously vice president and general manager of a global businesses unit within GE Healthcare IT, is also a proponent of standards-based APIs to enable evolution and innovation in healthcare. At the eHealth Initiative meeting he spoke eloquently about the need for data liberation and data liquidity. He said that terminologies should be standardized across vendors so that APIs can be used to send data between disparate systems readily and give health systems the ability to expose data to others to start to innovate.
Seeing its own health IT platform as the base of an ecosystem, Bay State has created a Tech Spring incubator. “We have opened it up to entrepreneurs to develop apps on top of our data,” he said. “It enables us to have conversations and influence on the types of apps being developed around continuity of care. We would love to see the open API movement take off,” he added. “That is the first part of the problem we need to solve.”