The HITECH act of 2009 (part of the American Recovery and Reinvestment Act) gave an unprecedented boost to an obscure corner of the IT industry that produced electronic health records. For the next eight years they were given the opportunity to bring health care into the 21st century and implement common-sense reforms in data sharing and analytics. They largely squandered this opportunity, amassing hundreds of millions of dollars while watching health care costs ascend into the stratosphere, and preening themselves over modest improvements in their poorly functioning systems.
This was not solely a failure of EHR vendors, of course. Hospitals and clinicians also needed to adopt agile methods of collaborating and using data to reduce costs, and failed to do so. They’re sweating profusely now, as shown in protests by the American Medical Association and major health care providers over legislative changes that will drastically reduce their revenue through cuts to insurance coverage and Medicaid. EHR vendors will feel the pain of a thousand cuts as well.
I recently talked to Dr. Travis Good, CEO of Datica that provides data integration and storage to health care providers. We discussed the state of EHR interoperability, the roles of third-party software vendors, and in particular the new “app store” offered by Epic under the name Orchard. Although Datica supports integration with a dozen EHRs, 70% of their business involves Epic. So we’ll start with the new Orchard initiative.
The Epic App Store
Epic, like most vendors, has offered an API over the past few years that gives programmers at hospitals access to patient data in the EHR. This API now complies with the promising new standard for health data, FHIR, and uses the resources developed by the Argonaut Project. So far, this is all salutary and positive. Dr. Good points out, however, that EHR vendors such as Epic offer the API mostly to extract data. They are reluctant to allow data to be inserted programmatically, claiming it could allow errors into the database. The only change one can make, usually, is to add an annotation.
This seriously hampers the ability of hospitals or third-party vendors to add new value to the clinical experience. Analytics benefit from a read-only data store, but to reach in and improve the doctor’s workflow, an application must be able to write new data into the database.
More risk springs from controls that Epic is putting on the apps uploaded to Orchard. Like the Apple Computer store that inspired Orchard, Epic’s app store vets every app and allows in only the apps that it finds useful. For a while, the terms of service allowed Epic access to the data structures of the app. What this would mean in practice is hard to guess, but it suggests a prurient interest on the part of Epic in what its competitors are doing. We can’t tell where Epic’s thinking is headed, though, because the public link to the terms of service was recently removed, leaving a 404 message.
Good explained that Epic potentially could track all the transactions between the apps and their users, and in particular will know which ones are popular. This raises fears among third-party developers that Epic will adopt their best ideas and crowd them out of the market by adding the features to its own core system, as Microsoft notoriously did during the 1980s when it dominated the consumer software market.
Epic’s obsession with control can be contrasted with the SMART project, an open platform for health data developed by researchers at Harvard Medical School. They too offer an app gallery (not a store), but their goal is to open the repository to as wide a collection of contributors as possible. This maximizes the chances for innovation. As described at one of their conferences, control over quality and fitness for use would be exerted by the administrator of each hospital or other institution using the gallery. This administrator would choose which apps to make available for clinical staff to download.
Of course, SMART apps also work seamlessly cross-platform, which distinguishes them from the apps provided by individual vendors. Eventually–ideally–FHIR support will allow the apps in Orchard and from other vendors to work on all EHRs that support FHIR. But the standard is not firm enough to allow this–there are too many possible variations. People who have followed the course of HITECH implementation know the history of interoperability, and how years of interoperability showcases at HIMSS have been mocked by the real incompatibilities between EHRs out in the field.
To understand how EHRs are making use of APIs, we should look more broadly at their role in health care. That will be the topic of the next section of this article.