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EMRs, APIs, App stores & all that: More data

By MATTHEW HOLT, with OLIVIA DUNN & KIM KRUEGER

Today I’m happy to release an update to some unique data about a pressing problem–the ability of small health tech vendors to access data from the major EMR vendors and integrate their applications into those EMRs. For those of you following along, in 2016 when Health 2.0 first ran this EMR API survey, we confirmed the notion that it’s hard for small health technology companies to integrate with the EMR vendors. Since then the two biggest vendors, Epic & Cerner, have been much more aggressive about supporting third party vendors, with both creating app stores/partnership programs and embracing FHIR & SMART on FHIR.

In 2018, we conducted a follow-up survey to see if these same issues persisted and how much progress has been made. In this report, we break down the results of the 2018 survey and compare them to the results of our 2016 survey. As in 2016, survey response rates weren’t great, but in this year’s survey we asked a lot more questions regarding app store programs, specific resources accessed, troubling contract terms and much more. And if you look at the accompanying slides, we also pulled some juicy quotes.

The key message: In 2016 we said this, The complaint is true: it’s hard for smaller health tech companies to integrate their solutions with big EMR vendors. Most EMR vendors don’t make it easy. But it’s a false picture to say that it’s all the EMR vendors’ fault, and it’s also true that there is great variety not only between the major EMR vendors but also in the experience of different smaller tech companies dealing with the same EMR vendor.

In 2018, things are better but not yet good. A combination of government prodding (partly from ONC implementing the 21st Century Cures Act, partly in the continued growth of pay for value programs from CMS), fear of Apple/Google/Amazon, genuine internal sentiment changes at least at one vendor (Cerner), and maturity in dealing with smaller applications vendors from three others (Allscripts, Athenahealth, Epic), and the growth of third party integration vendors like Redox and Sansoro, is making it easier for application vendors to integrate with EMRs. But it’s not yet in any way simple. We are a long way from the all-singing, all-dancing, plug-in interoperability we hoped for back in the day. But the survey suggests that we are inching closer. Of course, “inching” may not be the pace some of us were hoping to move at.

All the data is in the embedded slide set below, with much more commentary below the fold.

Health 2.0 EMR API report 2018

It’s getting better but….EMR Vendors are still a bottleneck
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Integrating with EMR vendors? Tell us More! The 2018 Health 2.0 API Survey

TL;DR  Accessing and using APIs from major EMR vendors has proved a real problem in the past — in 2016, Health 2.0 (with support from CHCF) collected the data to prove it. This year, we’re updating the survey and are asking again: how hard is it for smaller tech companies to integrate their solutions with big EMR vendors? Take the survey here.  

In 2016, Health 2.0 conducted a survey of health tech startups on behalf of the California Healthcare Foundation (CHCF) to shed some light on the difficulties around integrating third party applications–mainly from a new generation of health technology companies–into major electronic medical records (EMRs). The data was revealing, and confirmed that much of the anecdotal gossip was true: it is a challenge for smaller health tech companies to integrate their solutions with the major EMR vendors. There is no clear path to integration or data access, fees are sometimes involved, and even without fees, the lengthy process is too complicated and costly for small companies to handle. Of course, the problem of integration and data access is not limited to major EMR vendors. Healthcare providers and other data custodians may well be complicating the process, too.

In 2016, this survey found an incredible diversity of experience across the major EMR vendors (i.e. working with Epic is different than working with athenahealth), as well as an incredible diversity of experience across different tech companies dealing with the same EMR vendor. We want to know more. Now, Health 2.0 is reprising our previous work, looking once again to collect concrete data around this problem. Will the data reinforce what we found in 2016 or will there be some measure of progress in the past few years?

Much has changed since the first version of this survey, including a flurry of activity around Epic and Apple’s Healthkit integration, Cerner’s Ignite initiative, and the Carin Alliance. We want to know if any of that has made an impact for those looking to integrate. If you are a tech company that has experience with these issues, take this survey. Help us understand where we stand.    

The data and commentary collected here will be used to generate a set of slides, charts, and graphs that will be shared on THCB and at Health 2.0 Conferences, and will provide another year of data and much-needed transparency around the issue of integration. Responses will be kept anonymous by Health 2.0

Matthew Holt is Publisher of THCB & Co-Chairman Health 2.0. Kim Krueger is Research Director at Health 2.0

Accessing & Using APIs from Major EMR Vendors–Some Data at Last!

Today I’m happy to release some really unique data about a pressing problem–the ability of small tech vendors to access health data contained in the systems of the major EMR vendors. There’ll be much more discussion of this topic at the Health 2.0 Provider Symposium on Sunday, and much more in the Health 2.0 Fall Annual Conference as a whole.

Information blocking, Siloed data. No real inter-operability. Standards that aren’t standards. In the last few years, the clamor about the problems accessing personal health data has grown as the use of electronic medical records (EMRs) increased post the Federally-funded HITECH program. But at Health 2.0 where we focus on newer health tech startups using SMAC (Social/Sensor; Mobile OS; Cloud; Analytics) technologies, the common complaint we’ve heard has been that the legacy–usually client-server based–EMR vendors won’t let the newer vendors integrate with them.

With support from California Health Care Foundation, earlier this year (2016) Health 2.0 surveyed over 100 small health tech companies to ask their experiences integrating with specific EMR vendors.

The key message: The complaint is true: it’s hard for smaller health tech companies to integrate their solutions with big EMR vendors. Most EMR vendors don’t make it easy. But it’s a false picture to say that it’s all the EMR vendors’ fault, and it’s also true that there is great variety not only between the major EMR vendors but also in the experience of different smaller tech companies dealing with the same EMR vendor. All the data is in the embedded slide set below, with much more commentary below the fold.

Epic Systems’ Open Platform Will Bring U.S. Health Care Delivery Into the 21st Century

thcbEpic Systems, the market leader in electronic health record software (EHR), recently made a quiet but potentially transformative announcement that may finally shake the healthcare industry out of its technological doldrums.

Epic said it is prepared to support the creation of a more open interoperability platform for integration with other diversified healthcare applications. This will attract substantial investment to create software that operates, hopefully seamlessly, within the Epic EHR infrastructure.  Expect Epic’s competitors to follow suit, eventually opening up the marketplace of installed EHRs to third-party software developers and the efficiencies of modern, post-EHR technology ecosystem.

Epic’s critics have often denounced the company for selling a mostly closed technology, dampening hopes for the creation of an ecosystem of best-of-breed applications that work together with the EHR to automate much of the care delivery infrastructure beyond patient intake and billing.  The value of such an infrastructure is extremely compelling and so the company is under enormous pressure from its customers to become more open.

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Universal EHR? No. Universal Data Access? Yes.

A recent blog posting calls for a “universal EMR” for the entire healthcare system. The author provides an example and correctly laments how lack of access to the complete data about a patient impedes optimal clinical care. I would add that quality improvement, clinical research, and public health are impeded by this situation as well.

However, I do not agree that a “universal EMR” is the best way to solve this problem. Instead, I would advocate that we need universal access to underlying clinical data, from which many different types of electronic health records (EHRs), personal health records (PHRs), and other applications can emerge.

What we really need for optimal use of health information is not an application but a platform. This notion has been advanced by many, perhaps most eloquently by Drs. Kenneth Mandl and Isaac Kohane of Boston Children’s Hospital [1,2]. Their work is being manifested in the SMART platform that is being funded by an ONC SHARP Award.

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Two Contrasting Approaches to Health Care’s API Revolution

It’s heavy tech time at THCB. Health 2.0 is running a developer conference called Health:Refactored on May 13-4, and a big topic there will be the opening of APIs from Microsoft, Intel, Walgreens, NY Health Information Network, MedHelp, Nuance and more. What’s an API, why does it matter for health care? Funny you should ask but Andy Oram from O’Reilly Radar wrote an article for THCB all about it!–Matthew Holt

As the health care field inches toward adoption of the computer technologies that have streamlined other industries and made them more responsive to users, it has sought ways to digitize data and make it easier to consume. I recently talked to two organizations with different approaches to sharing data: the SMART platform and the Apigee corporation. Both focus on programming APIs and thus converge on a similar vision off health care’s future. But they respond to that vision in their own ways. Differences include:

  • SMART is an open source project run by a medical school and is partially government-funded; Apigee is a private company.
  • SMART tries to establish a standard; Apigee accepts whatever APIs its customers are using and bridges between them.
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Beyond HIT Operability: Open Platforms Are Key

I want to begin by sharing well-known information for the sake of comparison. Both the Apple and Google Android platforms welcome the introduction of new and (sometimes) highly valuable functionality through plug-n-play applications built by completely different companies.

You know that already.

Healthcare IT companies welcome you to pay them great sums of money for enhancements to their closed systems. This is on top of substantial maintenance fees that may or may not lead to hoped-for updates in a timely fashion. (With all due respect to the just-announced CommonWell Health Alliance, Meaningful Use does mandate interoperability. The participants are, in effect, marketing what they have to do anyway to try to differentiate themselves from Epic.)

The respective results of these two divergent approaches are probably also familiar to you.

Consumer technology has taken over the planet and altered almost every aspect of our lives. These companies and industries have flourished by knowing what customers will want before those same customers feel even a faint whiff of desire. We are both witnesses to and beneficiaries of dazzling speed-to-solution successes.

Back on planet health IT, the American College of Physicians reports that the percentage of doctors who are “very dissatisfied” with their EHRs has risen by 15 percent since 2010; in a poll, 39 percent said they would not recommend their EHR to colleagues and 38 percent said they would not buy the same system again.

I will argue that the difference between health IT and every other progressive, mature industry is the application of open source, open standards and, most importantly, open platforms. These platforms supporting interoperability and substitutability have enabled Apple and Google—and NOAA weather data, the Facebook Developer Platform, Amazon Web Services, Salesforce, Twitter, eBay, etc.—to drive innovation and competition instead of stifling it. They have created markets where everyone wins—the client, the application developer and the platform company.

The keys to open platforms are application programming interfaces (APIs) through which a platform-building company (i.e., Apple, Google) welcomes the contributions of clients and other companies. The more elegant the API, the more it can support true interoperability.

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