APIs: A Path to Putting Patients at the Center

I remember when visiting a city required paper maps and often actual guidebooks. Today, I tap on a map app on my phone, enter my destination, and review options for getting from point A to point B. In recent years, these applications have expanded to integrate ride-sharing, bike-sharing, and public transit information. Map apps provide two key real-time data points to help me compare the different options: the time it will take to get to my destination and the cost.

Behind those data points are elegant algorithms that analyze traffic patterns and conditions, as well as the real-time data exchange between multiple apps through modern, REpresentational State Transfer (RESTful) application programming interfaces (APIs). What makes our smartphones so powerful is the multitude of apps and software programs that use open and accessible APIs for delivering new products to consumers and businesses, creating new market entrants and opportunities. There is nothing analogous to this app ecosystem in healthcare.

ONC’s interoperability efforts focus on improving individuals’ ability to control their health information so they can shop for and coordinate their own care. While many patients can access their medical information through multiple provider portals, the current ecosystem is frustrating and cumbersome. The more providers they have, the more portals they need to visit, the more usernames and passwords they need to remember. In the end, these steps make it hard for patients to aggregate their information across care settings and prevent them from being empowered consumers.

Just as consumers can see the time to destination and costs using their map apps, they should be able to see quality indicators and costs of their care. As Health and Human Services (HHS) Secretary Azar recently stated, “putting the healthcare consumer in charge, letting them determine value, is a radical reorientation from the way that American healthcare has worked for the past century.” I certainly recognize that issues around pricing for healthcare services and measuring quality are complex, but I am confident that ONC’s efforts will complement new policies across HHS to encourage transparency, leverage Medicare and Medicaid to drive value-based transformation, and reduce regulatory burden on the health system.

As part of ONC’s role in coordinating health information technology (health IT) nationally, we are working with innovators to develop modern APIs that support the use of mobile apps to help individuals manage their own health or the health and care of a loved one. A robust health app ecosystem can lead to disease-specific apps and allow patients to share their health information with researchers working on clinical trials to test a drug or treatment’s efficacy, or monitoring outcomes like those in the National Institutes of Health’s All of Us Research Program.

ONC took a practical step to accelerate the use of APIs in healthcare with the 2015 Edition of the certification criteria adopted as part of the ONC Health IT Certification Program. Specifically, the 2015 Edition includes updated technical requirements that were not available in the prior edition and—to the benefit of the provider and the patient—to support further innovation in APIs and interoperability-focused standards. The 2015 Edition includes “application access” certification criteria that require health IT developers to demonstrate their products can provide application access to core medical and patient information via an API.

The 21st Century Cures Act (Cures) builds on ONC’s 2015 Edition and calls for the development of APIs that do not require “special effort” for developers to access and exchange health information. ONC will address this requirement through rulemaking expected to be issued later in 2018. Ensuring that APIs in the health ecosystem are standardized, transparent, and pro-competitive are the central principles guiding our work. These goals should allow new business models and tools that will expand the transparency of all aspects of healthcare. New tools should allow patients to comparison shop for their healthcare needs like they do when hailing a ride.

In recent years, the health IT industry has made positive strides. The HL7 Argonaut Project, a private sector initiative, has been developing a core set of Fast Healthcare Interoperability Resources (FHIR) implementation specifications. These specifications will enable expanded information sharing for electronic health records and other health IT solutions based on modern computing standards (i.e., REST, Javascript Object Notation (JSON), and FHIR). Boston Children’s Hospital Computational Health Informatics Program and the Harvard Medical School Department for Biomedical Informatics have been leading the development of SMART Health IT, an open, standards-based technology platform that already is showing success in enabling innovators to create apps that seamlessly and securely run across the healthcare system.

The convergence of these actions, the new authorities granted to ONC by Congress in the Cures Act, and efforts by HHS, the Centers for Medicare & Medicaid Services (CMS), the National Institutes for Health (NIH), and the Veterans Administration (VA) with the MyHealthEData initiative are helping promote more consistent data flows, inject market competition in healthcare, and return individual control of their care to the American public.

Don Rucker, MD is National Coordinator for Health Information Technology

Categories: Uncategorized

12 replies »

  1. Hi Dr. Rucker,

    Here are some comments regarding the Interoperability Standards Advisory (ISA) request for feedback that might help “putting patients at the center” by giving innovative developers access to data currently locked in the bowels of an EHR.

    Here is what is stated in the ISA document:
    “Additionally, standards are needed for openly accessible electronic health record application program interfaces (APIs) to assure interoperability with other health information technologies and third party applications.”

    While standardization of documentation for purposes of research, clinician communication and patient access are laudable goals – the Cures Act is clear in its language that APIs are required to avail ALL the data elements in a patient record. If true interoperability is to be achieved then the Cures Act mandates must be followed:

    Comment 1:
    FHIR is a documentation specification – not an API

    Please note FHIR is a documentation standard not an API. FHIR is a documentation standard derived from the HL/7 model. The availability of FHIR documents via an API merely represent a subset of the data requirements clearly stated in the Cures Act:

    “(iv) has published application programming interfaces and allows health information from such technology to be accessed, exchanged, and used without special effort through the use of application programming interfaces or successor technology or standards, as provided for under applicable law, including providing access to all data elements of a patient’s electronic health record to the extent permissible under applicable privacy laws…”

    Please note “all elements of a patient’s record” – not just documents (FHIR documents) extracted from a patient’s record – are required under the Cures Act.

    A FHIR API alone will not qualify an EHR for certification. Standardized documents are useful in the exchange of information but standardized documents do not represent all the data elements of a patient’s record that are contained in the database of an EHR.

    Comment 2:
    Here is a simple question for an EHR wishing to be certified or re-certified:

    Does your EMR make available open APIs to access ALL data elements of a patient’s electronic health record contained in your databases as entered by your users? YES or NO ?

    A) If NO –
    For EHRs applying for re-certification:
    Your EHR certification will be suspended for 6 months from the expiration date of your current certification. Please note a suspended EHR will no longer be permitted to add or recruit new customers or users until the terms of interoperability stated in the Cures Act are met.

    For EHRs applying for initial certification:
    Kindly re-apply when the terms of interoperability stated in the Cures Act are met.

    B) If YES – please provide to the ONC a public link for verification of your API, a description of the technical requirements, AND a detailed description of any costs to be incurred to access or transact with your API.

    Finally – how about adding a column to the ONC website that clearly details the responses to the above question by the EMR companies.

    All the best,
    George Krucik, MD MBA

  2. “Action that will begin to level the playing field for services that actually work for the physician and the patient without censorship by the hospitals and EHR vendors”

    Why would they ever do that?

    As a recent adopter of a major EHR (through my employer), it is perfectly evident that the “product” the EHR is selling is streamlined upcoding of services, full stop, end of story. Providers are failing to “capture acuity” or to “enhance the rev cycle”, not “failing to figure out what’s wrong with the patient and what to do about it”.

    I don’t know that hospitals and EHR vendors are engaging in censorship. But ask yourself this: “What business would spend seven figures on a product with no ROI?” None, right? Then ask yourself, “What IS the ROI that justifies a seven figure investment?”

    Hint: It’s not medication reconciliation.

  3. The sentiment in most of my colleagues has been pretty passive and resigned. Doctors are reluctant to organize against their oppressors. Or maybe it’s Stockholm Syndrome. Our profession is being turned into technicians (licensed employees responsible to their employer rather than to their patient) as we lose control of our profession’s essential tools.

    The first step is recognizing we have a problem. The next step is envisioning Physicians Anonymous to start taking responsibility for the problem rather than pretending it’s being done to us by “them”.

    What are you doing about it, Peter?

  4. ” Those who have studied previous movements (such as the LGBT social movement, thee Civil Rights movement, and the women’s suffrage movement) took a group of like-minded individuals from different walks of life who struggle together, make their voices heard, participate, and ultimately control the cultural narrative to the point that government had no choice but to abide to the sea change that has already taken place. This is where physicians and patients have to start.”

    So docs and patients are going to organize marches on Washington? I can just see the board of the AMA carrying placards and leading this march LOL.

    “(HIE of One)”

    How many docs/patients are using this now? Will insurance and CMS accept it for billing? How can I, as a patient, use this now?

  5. Physicians (and patients too) are angry and frustrated. We are frustrated with our clinical workflow impediments. For some of us, we are fed up with the perversity of the health IT industry where ONC, CMS, VA being are complicit. Some of us had seen it before when Meaningful Use came along and shattered some physician’s dreams of having an independent practice. I was a victim too. No longer.

    We (as in physicians and patients) HAVE the tools necessary to fight the digital products or promises being forced upon us with BETTER technology that is in our hands. It’s been published here on THCB – https://thehealthcareblog.com/blog/2017/07/27/this-ehr-mess-were-in/. We NO LONGER have to be on the sidelines. We NO LONGER have to to wait for CMS and ONC to listen to us. We have to be the agents for change. We have a legitimate cause. We have a platform (HIE of One) that is community and standards driven (meaning open to all physicians and patients). It is really our only way to push back against the tides that continue to batten down our profession through censorship and/or loss of choice.

  6. Nice little study in JAMA Onc showing patients perceive docs using paper as better communicators, more compassionate and more professional than those glued to a computer screen.

    Patients aren’t stupid.

    When will our “thought leaders” admit that the Emperor has no clothes?

  7. It’s crunch time for ONC, CMSs, and VA. After a decade of health IT policies that consolidate power in the hands of large provider institutions and their large EHR vendors, the time has come for ONC to take information blocking and patient-directed exchange beyond the nice words, to action. Action that will begin to level the playing field for services that actually work for the physician and the patient without censorship by the hospitals and EHR vendors.

    ONC has yet to take any action. And CMS and VA are lagging.

    The issue is fairly simple and was well documented by the API Task Force: Can a small, independent startup serving patients or physicians have access to the the FHIR API if the patient says it should – period?

    The technical capability is there and already demonstrated by Apple across over a hundred major hospitals and the largest EHR vendors. It’s based on FHIR and OAuth Refresh Tokens and there’s no app registration barrier as long as the app is Apple. Mind you, I love Apple because they are truly serving the patient here and have no access to the data itself. But Apple is the largest company in the world by many measures and their offering is not designed to serve physicians at this time. To enable the innovation and competition to serve patients and physicians that this administration talks up, we need specific, immediate action to level the playing field for other patient-directed innovations that aren’t as large as Apple.

    We need CMS and VA to implement Refresh Tokens and Dynamic Client Registration (as in the HEART Workgroup standards co-chaired by ONC!) immediately. What are they waiting for?

    We need ONC to declare the blocking of Refresh Tokens and Dynamic Client Registration under patient direction as “information blocking” under 21C Cures. Period. What are you waiting for?

    Lacking this action, the hospitals, EHR vendors, and various would-be intermediaries like CARIN Alliance are defining FHIR Refresh Tokens and Dynamic Client Registration as a premium feature accessible to Apple and maybe the All of Us program but not to the smaller innovators and physician-led projects like the open source HIE of One project.

    ONC, CMS, and VA, it’s time to put actions to enable practical patient-directed exchange behind the very nice words.

  8. Quite a bit more than a decade in my opinion. The EMR I am working on right now looks like Windows 95 Pac-Man. There is no way to complete a sensible statement using “EMR” and “future” at this point. Only a few years into this hapless technology and we are entrenched in stagnant legacy systems that barely work and cost a fortune. Massive failures like this only come around every few lifetimes, so take a good look ONC/CMS…YOU BLEW IT!

  9. Presumably, the Federal government’s rule making process will “…return individual control of their care to the American public…” Meanwhile, a major metropolitan city’s 911 center has now evolved into the “medical TRIAGE” processes to manage its “call burden.” Does this means that many citizens trust 911 more than their Primary Physician?

    If you awake one morning to find a “lump” somewhere underneath the skin that wasn’t there two weeks ago, would you expect a 911 center to arrange a same day appointment for you with your Primary Physician? Remember, the clock runs out in exactly 2 weeks to achieve a timely biopsy. Furthermore, how can we assure that this is true for every citizen, community by community?

    One estimate for the proximate determinants of a person’s Unstable HEALTH is proportionally related to 40% ‘socioeconomic,’ 30% ‘personal life-style,’ 20% ‘healthcare’ and 10% ‘community environment’ FACTORS. I would propose that any proposals for healthcare reform have an explicit connection with the other factors, community by community. A person’s HEALTH is and will always be locally driven, especially its Primary Healthcare.

  10. Blah blah blah…the one thing you failed to mention is that Apple and Google both do API’s WITHOUT the US government’s heavy hand. They compete for developers. Have you EVER tried to ask Cerner or Epic for access to their API’s, its a total mess, a huge special effort, and just does NOT happen at all for anyone not willing to pay to play. They do NOT want you to use them.
    So lets back up…we have tried the Certified EHR and it left us here…dejected, burned out MDs that are using 1990’s technology that does NOTHING to improve the Triple Aim, and obviously failed the Quad Aim.
    Its time that ONC and CMS just stop all the certified madness, the hyper-regulatory action and just get out of the way of real competition. The artificial market made by HITECH has nearly destroyed the practice of medicine and further actions by the tone deaf ONC leaders and HIT leaders that can’t seem to understand that why their heavy regulatory action has not brought about positive change… you just need to go away…
    So thanks ONC, CMS, but get out of the exam room, get out of the way of MDs and patients. We know what we need, stop trying to regulate and think for us. Let REAL innovation happen, we do NOT need to be babysat for our products. Stop CertEHR, Stop MIPS MACRA and counting attesting for quality points.
    Do you understand you have failed Mr Rucker? Stop all the puffery language and “Value Based” talk and how you are gonna help clarify “special effort”. Just stop and let innovation come back in. You have set us back AT LEAST a decade of real progress.