- Robert Huckman
- Maya Uppaluru
Leaders of most internet-based businesses have realized the critical importance of using open application programming interfaces (APIs) to expand the reach of their organizations. If the health care industry followed suit, the impact on the quality and cost of care, the patient’s experience, and innovation could be enormous.
APIs are programming routines or protocols that allow software applications to share data. Organizations such as Amazon, IBM, Salesforce.com, Facebook, and Google, have all engaged in substantial API “releases” that permit developers to access information so they can build new applications or businesses. For many of these organizations, there is massive potential to create new value. Ultimately, this type of innovation serves the end customer — creating better functionality and experience for the user.
The impact of open, standardized APIs in health care would be even more significant. In a health care market where APIs are commonplace, patients could have easy, efficient access to their own data, which would help them understand their own health and make more informed choices. Providers would be empowered by innovative user interfaces and analytics platforms that could support their clinical decision making. Researchers could have easier access to detailed clinical and claims data to create hypotheses and identify trends — and create a better experience for individuals donating their data for science. Finally, the availability of data would lead to the development of an entirely new group of health care innovators: developers who do not have particular expertise in health care but, when given secure access to clinical data from the industry, could create tools of significant value. Together, these benefits could allow the health care system to tap the true potential of its massive data resources.
Efforts to “liberate” health care data for third-party applications have progressed slowly, because the sector lacks the robust APIs and app developer programs common in other industries. This creates major challenges with respect to care quality, safety, and cost. For example, consider the case in which a stroke patient is prescribed a clot-busting medication in the ER, but the record of her dosage does not follow her seamlessly to other units within the same hospital. Even worse, the full record of her ER stay may not follow her back to her primary care provider. Similarly, the parents of a child with diabetes may not be able to get access to their child’s records, impairing their ability to monitor their child’s condition effectively.
In the United States, the American Recovery and Reinvestment Act of 2009 introduced the Medicare and Medicaid EHR Incentive Program, which is administered by the Centers for Medicare and Medicaid Services (CMS). This program provided financial incentives to adopt certified EHR technology systems and includes requirements that specific providers “meaningfully use” these systems. As a result of this program, 97% of reported hospitals had certified EHR technology in 2014, up from 72% in 2011.
Their success in meeting meaningful use requirements affects the level of Medicare reimbursement that they receive. Among other objectives, meaningful use includes the requirement that providers enable their patients to (1) view, (2) download, and (3) transmit their health data to a third party (known as the “VDT” requirement). The most-recent meaningful use regulations — the widespread implementation of which is currently due to occur in 2018 — add a fourth requirement that patients be able to access their health information through an API via the application of their choice. This new functionality would not only enable EHR systems to share data with patients but would also help to create system-wide interoperability between different providers and EHR systems.
For patients and their caregivers, the benefits of interoperability and easier access to data via APIs are obvious. Today, patients often have to deal with a different patient portal for each provider they visit. Open APIs will make it easier for both vendors and start-ups to create web and mobile applications that retrieve patients’ clinical data from various EHR portals and aggregate the information in a single location.
For providers, who often report difficulty with using EHR technology, APIs represent an opportunity for internal innovation. Open APIs can allow provider systems to build their own custom user interfaces in-house or shop around for a better solution than the interface that comes standard with their EHR system. EHRs could eventually become a platform on top of which other companies could build more tailored applications and improve usability for clinicians.
For researchers, a less-obvious benefit of open APIs in health care is the potential created for a wide range of individuals or organizations to engage in “citizen science” by performing analysis of trends in utilization, cost, or outcomes using a large population of aggregate, anonymized medical records. The Stanford Children’s Health system in the San Francisco Bay Area has developed an open source, analytics platform for diabetes management, leveraging its EHR’s API and Apple Healthkit, which can be implemented by any physician to improve understanding of patient trends over time. The Stanford team works with the DexCom blood-glucose-monitoring device, which has an app that sends continuous patient data into the EHR, allowing patients and their providers to make shared decisions about treatment.
Other projects like the Personal Genome Project are aggregating individually donated genome, health, and trait data from thousands of participants to help citizen scientists interpret genetic variants. PatientsLikeMe, an online clinical-research platform driven by individual data donation, aims to deliver real-time patient insight into many diseases and conditions. In some cases, it has raised questions about established approaches to treatment. In 2011, a patient-initiated observational study using the PatientsLikeMe platform was published, refuting a 2008 study claiming that lithium carbonate could slow the progression of amyotrophic lateral sclerosis (ALS). With easier access to clinical data, authorized and mediated by the participant, open databases like this could become powerful tools for fueling precision medicine and data-driven, individualized care.
Given their significant potential to improve value in health care, the immediate question is how we can accelerate progress toward broader use of open APIs within the industry. We see four main needs in this regard:
1. Financial incentives for providers need to encourage the data exchange necessary to deliver better outcomes. The health care industry is in the midst of a massive shift away from fee-for-service models to value-based care that ties reimbursement to better outcomes, lower costs, and higher patient satisfaction. Payments under Medicare’s new merit-based incentive payment system (MIPS) as well as new incentives for professionals participating in alternative payment models will go into effect starting in 2019. Both these programs contain requirements for providers to leverage certified EHR technology to improve care delivery. When providers face an incentive to exchange data to support better outcomes, the business case for implementing APIs becomes much clearer.
2. The concerns of both patients and providers around privacy and security must be addressed. There are legitimate security issues that arise with exchanging data. However, the rest of the consumer and business internet has adopted and extensively deployed standards for the secure exchange of sensitive data like OAuth 2.0 and Open ID Connect to facilitate authentication and authorization using APIs. While the health care industry and health data is certainly subject to unique security and privacy considerations, providers can benefit from leveraging these standards and safeguards to support patient access, while preserving privacy, security, and patient preferences.
4. Cultural and workflow issues within health systems must be addressed. Providers often fear being paralyzed by a deluge of data when APIs are implemented that allow patient-generated data to enter the system — or fear that releasing data may cause them to lose patients. When APIs are implemented in practice, however, these fears are rarely realized. To the contrary, modern technology and analytics have the potential to add value to the decision-making process for providers and patients; in other industries we’ve found that making systems interoperable improves both the user experience and retention of customers. At Ochsner Health System, a pilot program to prevent heart failure and hypertension used an API to collect body weight and blood pressure data from over 500 individuals’ connected devices, leading to significant reductions in hospitalizations and improved blood pressure control. Despite initial provider concerns, the results from these and other pilots across the country have shown the potential of APIs to improve care and create a better experience for patients and providers alike.
To truly build a health care system that can evolve at the rapid pace of technology and science, we must tackle these formidable challenges head on. Open APIs provide massive potential for increased patient empowerment and shared decision making between providers and patients that may transform the delivery of health care.
This article is the result of independent research and does not represent the views of the White House, the Office of Science and Technology Policy, or any other entity of the U.S. federal government.