Matthew Holt is co-chair of Health 2.0. At the Dev4Health conference in Cleveland on Monday andTuesday, he and Health 2.0 cofounder Indu Subaiya presented their assessment of the drivers of the new interoperability in healthcare. This is a summary of some of their remarks, and Holt's other observations from the conference. If you are interested in this topic please take the ongoing Health 2.0 EMR-API survey.

Since Health 2.0 was founded back in 2007 the role of developers has become more central to the health technology ecology. Of course, this mirrors a wider role in the rest of the tech economy, where the large vendors (Apple, Facebook, Amazon, Salesforce, Google et al) now each have huge ecosystems of smaller companies and independent developers that build tools and apps on their platform. Those developers and sell directly through the giant platforms and in many cases incorporate data from them and each other to provide services, influence consumers or (whoops!) sway elections.

HIMSS and Health 2.0 merged in 2017, and the Dev4Health conference is our new venture designed to rally the developer community in health care. Hal Wolf, CEO of HIMSS, told the crowd that the organization would develop a “slightly maniacal focus” on the topic of helping providers open their data to developers because the problems of health care can’t be solved by any one provider or EMR vendor acting alone. William Morris, senior medical director at Cleveland Clinic Innovations, gave essentially the same message—describing that organization’s tech program as a journey to let other organizations access (and disrupt) its current business processes. Health 2.0’s Indu Subaiya talks about moving health data from a metaphor of silos connected by bridges to one of semi-permeable membranes connecting cells that are always in motion.

But while the rhetoric about interoperability, exposing APIs, using the FHIR standard, and disruption flew thick and fast in Cleveland, the reality is that we aren’t quite there yet. Well-known techy physician Dr. Danny Sands recently tweeted out a letter received from the VNA in Boston telling him that they’d now be sending clinical notes using a new service called the fax machine! (No, this wasn’t an April Fools joke). Most systems still struggle to expose more than limited data, often in PDF format, and the promise of interoperation between systems often gets bogged down in long waits for patients and clinicians to access records, which leads to real-world frustration and, worse, poor care. ONC’s Margaux Anazawa recently completed a report showing how much this was still going on in the real world, and gave a talk at Dev4health suggesting ways to fix it.

And there are real world solutions now available. Most EMR vendors are now involved in programs like the Argonaut project and the Carin Alliance which are promoting the use of the FHIR standard. Meanwhile, the SMART on FHIR project is enabling app vendors to directly include their solutions within the workflow of major EMR vendors. EMR vendors (including representatives from Cerner, athenahealth and Allscripts) on a panel at Dev4Health suggested that their monopoly over the User Interface would fade, and their role would be more as “transaction systems of record” supporting a number of third party applications.

But some interim (and early) indications from work Health 2.0 has in the field, surveying tech companies that are trying to build on or integrate with major EMR vendors’ APIs, suggests that FHIR resources were not yet widely available for them to work on. However, the prevailing sentiment was that most major EMR vendors were showing modest improvements to providing API access. Indeed Allscripts and Cerner described how they are moving to FHIR-based APIs from their proprietary version. Likewise while only around 35 providers have “switched on” FHIR-based APIs, early indications are that the majority of smaller vendors perceive that providers in general are more interested helping them access data via APIs than they were just two years ago.

Cerner is a harbinger here. Its partner program really only started in 2016 and it still hosts fewer than 20 companies, but it has moved some 50 percent of its clients to its cloud-based API Ignite. Last fall at Health 2.0 we showcased a demo from Meducation, an app that used SMART on FHIR to launch from within Cerner’s main Millenium EMR. This is doubly notable as Meducation is owned by drug information vendor First Databank, which is a direct competitor to Cerner’s own drug information product Multum. So it’s a new world that is bound to be uncomfortable for vendors and providers alike but suggests that new collaborations will become the norm.

Finally, it’s not as if the rest of the tech world is standing still while health care begins to come up to speed. The App Store and Google Play are very well established and the new buzz in tech is about AI, VR, AR, blockchain, robotics, sensors, and much more. We had several companies showing their latest work in all of these areas at Dev4Health, and while it’s fair to say that this is for now mostly experimental, major players are moving fast. Change Healthcare (nee Emdeon) has built a blockchain transaction system in parallel to its old school clearinghouse, while UPMC is just one major provider experimenting with AI. The pressure will be on health care providers, payers, EMR vendors and all of us to incorporate these technologies to improve the health care experience.

And of course what we think of as health care is changing too. We need to integrated data from different aspects of people’s lives and distribute it differently too. Indu Subiaya likes to emphasize that “Health Happens Everywhere” and that complex problems like the current opiate epidemic show up in the health system, prisons, law enforcement, the workplace, schools and everywhere else, so we need to track data across that continuum. Whatever the multitude of complex problems in health care, if technology is to play a role, developers need to collaborate to co-develop useful solutions.

P.S. A plea. Health 2.0 is trying to establish the real state of play regarding EMRs, APIs, FHIR et al. Please take the ongoing Health 2.0 EMR-API survey to enable us to share the best knowledge on the topic. 

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