Healthcare Leader Should Embrace APIs

Originally published in Healthcare Information Management and Communications Canada magazine:

Despite their technical sounding name, Application Programming Interfaces (APIs) are a strategic weapon that can drive innovation, foster interoperability, and unlock the value of existing information systems. Just as leaders in industries as diverse as retail and finance have embraced APIs as a strategic imperative, so too should Healthcare leaders. 

Over the summer I had the perfect opportunity to pitch the benefits of APIs to a hospital leadership team and I blew it! I was interviewing to fill a vacancy on the leadership team and had been asked (as had the other candidates) to prepare a presentation on how the organization could optimize use of their recently deployed hospital information system replacement. APIs were part of my response. 

While many aspects of my presentation elicited nods and smiles, the mere mention of APIs was met with quizzical looks that quickly morphed into the dreaded “eyes glazed over” expression. I knew that I had failed to clearly explain APIs and why they matter when the CEO asked, “So, what exactly is an API?” 

As I am firm believer in the old adage, “if you at first you don’t succeed, try, try again”, I’m taking another run at convincing healthcare leaders to embrace APIs. 

The U.S. Office of the National Coordinator for Health Information Technology (ONC) describes APIs as “messengers or translators that work behind the scenes to help software programs communicate with one another.” APIs “describe a specific set of technical instructions that allow one piece of software to interact with another piece of software.” 

An October 2015 article in Forbes entitled Why Your CEO And Board Should Be Demanding API Adoption, asserts: 

“Given the benefits that companies of all sizes in a diverse collection of industries are getting from APIs, it is clear now that more CEOs and Boards of Directors should be delivering their own version of the Yegge rant.” (Written by Steve Yegge, formerly with Google, the rant includes a leaked communication from Amazon CEO Jeff Bezos in which he demanded that everyone at Amazon implement APIs or be fired). 

In a companion article entitled Don’t Get Ubered: APIs Hold Key To Digital Transformation, author Dan Woods argues: 

“In a larger sense, APIs are the secret sauce to becoming digital, that is, to transforming business so that innovation can happen at a faster pace, so that barriers to change are reduced, so that many more people can contribute to your company’s success, and so that you can create better products and defend yourself from the competition.” 

Robert S. Huckman, faculty chair of the Harvard Business School Health Care Initiative, and Maya Uppaluru, a policy advisor in the Obama administration’s White House Office of Science and Technology Policy, share Dan Wood’s views on the benefits of API. In a December 2015 Harvard Business Review article entitled “The Untapped Potential of Health Care APIs”, they assert: 

“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.” 

Many industries have embraced APIs. According ProgrammableWeb, Reference, Financial and Social are the leading users. The health sector, unfortunately, does not make the top ten on the ProgrammableWeb list. 

A Commonwealth Fund healthcare policy and practice commentary entitled “Making Health Data Useful to Patients Through Open APIs” puts the current use of APIs by the health into perspective: 

“APIs have the potential to remove many barriers to the sharing of health information between providers, patients, and others but they are fairly new to health care.” 

The ONC has recognized the transformative potential of APIs and views them as the means to overcome the interoperability challenge that has plagued the health sector. Certification criteria for electronic health record systems include reference to APIs. Since the majority of hospital information systems used in Canadian hospitals are from U.S. vendors, these hospitals can potentially leverage these same APIs. 

The Ontario Hospital Information System (HIS) Renewal Secretariat shares the ONC’s views on the transformative potential of APIs and has included API support as a core requirement that must be incorporated into Master Service Agreements and RFPs. Specifically, with respect to Data Access and Portability, the HIS Renewal Provincial Framework (draft) specifies that an HIS must “support access to the hospitals’ data by other health care solutions including through the use of published APIs.” 

The Harvard Business Review article that I referenced earlier describes the benefits of APIs for patients, healthcare providers, and researchers. With respect to optimizing use of hospital information systems (the topic I was asked to address in my interview), the article explains: 

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. 

What are your thoughts on the strategic importance of APIs? Are they strategic a strategic imperative that healthcare leaders, including CEOs, should embrace? 

Mike

 

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Digital Health: What’s Next?

My most recent “Last Words” article published in Health Information Management & Communications Canada magazine:

A good friend and former work colleague often remarks that once you have worked as a market analyst, you will always think like a market analyst. This observation rings particularly true around New Year’s when I feel the irresistible urge to offer my prognostications on what’s next for digital health.

This year, rather than offer specific predictions, I offer an overview of three major drivers that I believe will influence digital health priorities and direction in the near future.

Meaningful Use

In what might turn out to be one of the most significant announcements of 2016, Andy Slavitt, Acting Administrator of the U.S. Centers for Medicare and Medicaid Services (CMS), declared:

“The Meaningful Use program as it has existed, will now be effectively over and replaced with something better.”

According to healthIT.gov (a web site operated by the U.S., Office of the National Coordinator for Health Information Technology), Meaningful Use is defined as “using certified electronic health record (EHR) technology to:

• Improve quality, safety, efficiency, and reduce health disparities
• Engage patients and family
• Improve care coordination, and population and public health
• Maintain privacy and security of patient health information”

Speaking at the J.P. Morgan Annual Health Care Conference on January 11, 2016, Mr. Slavitt identified what he referred to as the four “themes guiding our implementation” of a Meaningful Use replacement:

• Reward healthcare providers for the outcomes they achieve using digital health technologies rather than simply for use of these technologies.
• Customized goals that allow solutions to be tailored to practice needs. Slavitt stated that “technology must be user-centered and support physicians, not distract them.”
• Levelling the playing field for start-ups and new entrants. This objective will be achieved by requiring open APIs in order to “move away from the lock that early EHR decisions placed on physician organizations” and thereby “allow apps, analytic tools, and connected technologies to get data in and out of an EHR securely.”
• Mr. Slavitt proclaimed “we are deadly serious about interoperability” and put technology companies that attempt to “practice ‘data blocking’ in opposition to new regulations” on notice when he stated that such practices “won’t be tolerated.”

Each of these themes reflects issues and challenges that have hampered the effective use of digital health technologies by both healthcare providers and the general public.

While the Meaningful Use program does not apply to Canadian healthcare organizations, it did have and its eventual replacement will have a significant influence on the digital health landscape in Canada.

Digital Health Investment

In their year end review for 2015, Rock Health, a venture fund dedicated to digital health, stated that venture funding for digital health companies in 2015 raised $4.5B.  This level of funding was an increase over the record breaking level of digital health investments in 2014 and, according to Rock Health, represents a compound annual growth (CAGR) from 2011-2015 of 32%.

Rock Health noted in their year end review that while “overall venture funding showed a slight dip in 2015, digital health continues to hold a healthy 7% of total venture funding.”  They also remarked that investors continue to show their interest in digital health companies and observed that there is a “growing tail of investors who participated in at least one deal.”

This steady level of funding and growing investor interest leads Rock to declare that “digital health is no longer a novelty.”

Rock Health identified three particular digital health categories that exhibited noticeable growth in funding in 2015: personal health tools and tracking, care coordination, and life sciences technologies.  They commented that “as the industry faces growing pressure to cut costs, digital health will play a key role in enabling engagement with the end-user and improving communication and coordination.”

Digital Everywhere

Computing technology, once the nearly exclusive realm of geeks and hobbyists, is now an integral part of everyday life for most people.

According to comScore, a global media measurement and analytics company, an average of 29.4 million Canadians per month accessed some form of on-line service during the fourth quarter of 2014.  Based on Statistics Canada figures, this on-line community represents just over 80% of the Canadian population.

Not only are a majority of Canadians engaging in some form of online activity, comScore notes that they are increasingly doing so across multiple devices including desktops, laptops, tablets, and smartphones. The number of Canadian mobile subscribers grew 5% from December 2013 to December 2014, with just over 80% of these subscribers owning a smartphone capable of accessing a variety of online services.

The pervasiveness of digital technology is changing how digital health solutions are perceived by end users.  Neither patients nor health providers need to be enticed to use digital technology; they do so in most other aspect of their lives. They need only be offered digital health solutions that are both useful and usable.

Summary

By clearly communicating its priorities and future direction, CMS is providing investors with insights that will shape their investment decisions.  This investment, if focused more on addressing user needs and less on certifying compliance with meaningful use guidelines, will likely produce digital solutions that end users will embrace and use.

What are your thoughts on digital health trends and drivers?  Please share your thoughts with me at michael.martineau@avenant.ca or on my blog at ehealthmusings.ca

The Interoperability Imperative

This article originally appeared in Healthcare Information Management & Communications Management magazine:

Call me a “fan boy” but I couldn’t wait to get my hands on Apple’s iPhone 6. Having written about the disruptive potential of digital health platforms, I was eager to play with apps designed for the new HealthKit platform (and that took advantage of the iPhone 6’s many built-in sensors). Even before I began to explore the functionality of the first HealthKit enabled app that I installed, I was struck by how it easyit is to share data among these apps. I simply indicated during the installation process which data elements I wanted to read from and write to the HealthKit repository and I was done. If only the sharing of my personal health data across the various health IT systems in which it is stored was so easy!

Interoperability, like innovation, is one of those words that has become so overused that it risks oblivion in buzzword hell. Equally concerning, it is a term that few people outside the health IT community use and care very little about. Yet, interoperability (or, perhaps, more correctly, lack of interoperability) has proven to be a major impediment to realizing the full potential of health IT.

Karen DeSalvo, Director of the Office National Coordinator for Health Information Technology (often referred to as the ONC) in the United States, has made impassioned pleas about the interoperability imperative at various events since she was appointed less than a year ago. At the annual HIMSS conference, held this year in Orlando, Ms. DeSalvo told attendees:

“We have made impressive progress on our infrastructure, but we have not reached our shared vision of having this interoperable system where data can be exchanged and meaningfully used to improve care.”

A similar situation exists in Canada. In a brochure advertising an interoperability workshop scheduled to take place in October 2014 (before this article is published), ITAC Health offers the following summary:

“For years the Health ICT industry in Canada has struggled with the challenge of interoperability. Application developers are faced with a dizzying array of standards, jurisdictional requirements and legacy environments.”

At the annual American Health Information Management Association (AHIMA) conference held this year in San Diego, Ms. DeSalvo observed that healthcare data “must be plug-and-play. It’s not helpful if it just sits there idle.”

I was intrigued by Ms. DeSalvo’s choice of words. To be useful, Ms. DeSalvo contends, healthcare data must be able to move to where it is needed. This notion of data liquidity, which the Institute of Medicine defines as “the rapid, seamless, secure exchange of useful, standards- based information among authorized individual and institutional senders and recipients”, captures the essence of what we are trying to achieve when we talk about interoperability.

So, how do we achieve data liquidity? Dr. Doug Fridsma, Chief Scientist at the ONC (and soon to be President and Chief Executive Officer for the American Medial Informatics Association (AMIA)), contends that tackling this challenge “from the top down isn’t going to work.”

In a HealthITBuzz (the ONC’s blog) post earlier this year, Dr. Fridsma offered insights on how to achieve interoperability on a large scale. These insights were gleaned from a Software Engineering Institute report entitled “Ultra-Large Scale Systems: The Software Challenge of the Future.” He notes that the characteristics of ultra-large-scale systems described in the SEI report have “an eerie similarity to the challenges we face in the overall health IT industry.”

“Ultra-large scale systems are not about a single software application, or a couple of applications working together, but rather an ‘ecosystem’ of interacting software systems,” notes Dr. Fridsma. These systems “cannot be managed ‘top down’ in a monolithic way, but will require a coordinated, decentralized way of meeting local needs, while keeping all of the systems working together.”

This notion of ecosystem is reflected in the ONC’s 10-year vision for an interoperable health IT infrastructure. This vision is based on what the ONC refers to as “five critical building blocks”

1. Core technical standards and functions
2. Certification to support adoption and optimization of health IT products and services
3. Privacy and security protections for health information
4. Supportive business, clinical, cultural, and regulatory environments
5. Rules of engagement and governance

These building blocks are similar to the key enablers that Canada Health Infoway lists in its Pan-Canadian Digital Health Strategic Plan.

Ken Stevens, VP, Healthcare Solutions, Intelliware Development
Inc. and Co-Chair of the ITAC Health Interoperability and Standards Committee, offers what I think is perhaps the best summary of the interoperability imperative. Commenting on one of my posts on the eHealth Musings blog, Ken writes:

“Interoperability and data mobility have a huge impact on whether innovation is even possible …. Wherever valuable data is accessible through simple open standards, innovation will flourish.”

What are your thoughts on the interoperability imperative? How can we achieve data liquidity? What needs to change?

Electronic medical record systems: Does one size fit all?

I love fall! Not only for the changing colours and cool, crisp days but also for the many conferences and trade shows that take place this time of year. At the recent HealthAchieve conference, organized by the Ontario Hospital Association, for example, I learned that there is a growing trend in Canadian hospitals towards a single, enterprise-wide electronic medical record system. Experience elsewhere in the world suggests that this preference for single vendor systems over best of breed environments is fraught with challenges and runs counter to the trend in other industries.

Check out the rest of this Technology for Doctors articles here.

Mike

Musings on the next eHealth Ontario CEO

Earlier this year Greg Reed, eHealth Ontario’s CEO, announced that he was resigning his position effective October 2013. Although there was a flurry of media attention when the resignation was announced, mainly focused on Mr. Reed’s severance package, there has been little speculation since then regarding Mr. Reed’s possible successor. Who are the possible candidates for this role?

See the remainder of my Technology for Doctors article here

Mike

Ontario Diabetes Registry – Doomed from the start?

Over the week several readers of my blog, eHealth Musings, have asked me to comment on eHealth Ontario’s recent decision to terminate its contract with CGI to build an electronic Diabetes Registry.  Check out my article on this topic at Technology for Doctors.

Mike

The Applification of the EMR

Perhaps one of the Steve Jobs’ greatest legacies is the iPhone and the app ecosystem that it supports.   Rather than trying to define and develop every bit of functionality that an iPhone has to offer, Apple handed the opportunity to do so to hundreds of other organizations, large and small. Apple gave up some control in exchange for unprecedented growth in market share and, ultimately, stock price.  Imagine for a moment if a similar approach was applied to the design of EMRs and other eHealth applications.  Might the same level of innovation and user adoption result?   A team led by Harvard University seems to think so and was awarded $15M by the U.S. Office of the National Coordinator for Health IT to turn their ideas into reality.

You can read the rest of my monthly Technology for Doctors column here.

Mike

U.S. funds Health IT Comptency Exams

As the U.S  engages in major effort to drive adoption and meaningful use of electronic health records, a shortage of Health IT professionals threatens to impede progress.   Indeed, the U.S. Bureau of Labour Statistics predicts a possible shortage of approximately 50,000 qualified Health IT professionals.

To combat this problem, the American Health Information Management Association (AHIMA) has launched the HIT Pro™ exams which, according to AHIMA, are designed to “assess basic competency of individuals who are seeking to demonstrate proficiency in certain health IT workforce roles integral to the implementation and management of electronic health information.”   These exams consist of 125 multiple choice questions and are expected to take three hours to complete.

The HIT Pro™ exams offer individuals who have taken a short-duration, non-degree health IT workforce development program or who have acquired relevant, on-the-job experience the means to demonstrate their health IT competency.   At this time, exams have been developed for six distinct competency profiles:

• Clinician/Practitioner Consultant
• Implementation Manager
• Implementation Support Specialist
• Practice Workflow & Information Management Redesign Specialist
• Technical/Software Support Staff
• Trainer

For a limited time, there is no cost to U.S. citizens to write one of the HIT Pro™ exams.   The cost is covered through funding from the U.S. Department of Health and Human Services (HHS). This program illustrates yet another way that the U.S. government is moving forward aggressively to deploy electronic health records across the continuum of care.  When potential roadblocks such as a potential shortage of qualified Health IT professionals is identified, it seems that program is quickly developed to address the problem in the most practical way possible.

Mike

• Clinician/Practitioner Consultant
• Implementation Manager
• Implementation Support Specialist
• Practice Workflow & Information Management Redesign Specialist
• Technical/Software Support Staff
• Trainer

Feedback May Impact ONC Timetable

The U.S. Office of the National Coordinator for Health IT (ONC) recently issued a call for comments on its proposed stage 2 and stage meaningful use requirements.  This call for comments has generated considerable feedback, most of which has been posted publicly and has been reported in various publications.   According to recent healthsystemCIO.com article, an ONC workgroup “will review the timing of its staging structure”.

Of particular interest to me was workgroup member Judy Murphy’s observation that “There appears to be a groundswell movement which has people sending (blog) postings back and forth.”.  Apparently, public debate using social media tools such as a blog can have an impact.

Mike

NIST Publishes EHR Usability Guidelines

Regular readers of my blog and the articles that I write for several publications will know that I have considerable concerns about the usability of physician office health IT systems (typically referred to as EMR in Canada and EHR in the US). The US Office of the National Coordinator for Health IT (ONC) shares my concerns [or, perhaps, I share their concerns :)] and has funded the US National Institute for Standards and Technology (NIST) to provide advice on how to improve the usability of EHR software.

According to a post on MedHealthWorld, NIST has released two publications related to EHR usability design and testing:

• NIST Guide to the Processes Approach for Improving the Usability of Electronic Health Records (NISTIR 7741) which offers advice on how to employ “user-centered-design” processes throughout an EHR product life cycle.
• Customized Common Industry Format Template for Electronic Health Record Usability Testing (NISTIR 7742) which provides a standard reporting format (known as the Common User Industry format) adopted and customized for testing EHR systems.

I am huge fan of user centered design. I have personally witnessed the level of user acceptance of the software produced using this approach. By actively engaging users throughout the design and development process, the likelihood of user acceptance is greatly increased. Indeed, I have seen users literally nagging developers as to when the software that they helped design would be ready for them to use.

Mike