Dr. Edmund Billing describes why open platforms are the key to health IT interoperability and how APIs are starting to become a reality in healthcare.
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 them 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.
In the platform, innovators see market opportunity—an invitation to build on the open platform without time-consuming business negotiations. For the open platform provider, APIs also provide key benefits:
- Increased value of the system and platform for clients (the right kind of lock-in)
- Expanded solutions for the client while the company focuses on system and platform
- More rapid and affordable innovation and customization
Most importantly, as described by Kenneth D. Mandl, M.D., M.P.H., and Isaac S. Kohane, M.D., Ph.D, in a 2009 New England Journal of Medicine article entitled “No Small Change for the Health Information Economy”, open platforms create new markets driven by innovation of substitutable choices:
The Apple iPhone, for example, uses a software platform with a published interface that allows software developers outside Apple to create applications; there are now nearly 10,000 [currently well over 300,000] applications that consumers can download and use with the common phone interface. The platform separates the system from the functionality provided by the applications.
And the applications are substitutable: a consumer can download a calendar reminder system, reject it, and then download another one. The consumer is committed to the platform, but the applications compete on value and cost.
Specifically regarding health IT, Mandel and Kohane say:
The system should be sufficiently modular and interoperable so that a primary care provider could readily use a billing system from one vendor, a prescription-writing program from another, and a laboratory information system from yet another. Individual systems do not need to perform all functions … Just as consumers may swap out applications on their iPhones, physicians should be able to readily replace one referral-management system with another … the platform should be built to open standards, accommodating both open-source and closed-source software …
Imagine, as Mandel and Kohane did, that health care organizations did not have to look to a single proprietary vendor for all solutions. What if they could go to a competitive marketplace of ever-evolving applications in a host of categories that could all plug and play, integrate and enable collaboration? The NEJM article envisions prescribing, physician order-entry, medication reconciliation and drug-safety alerts available in the Medication Management app store. Under Public Health Reporting, physicians can purchase and download plug-n-play notifiable disease reporting, bio-surveillance, and pharmacosurveillance tools. For Decision Support, laboratory-test interpretation, genomics and guideline management are available.
The creative potential for a healthcare app store is huge.
The open-platforms vision is starting to become a reality in health care. Open source code and standards support collaborative communities at Open Health Tools and the federal government’s Open Source Electronic Health Record Agent (OSEHRA). Commercialized versions of the VA’s much-lauded VistA system incorporate API-enabling open development tools like the OpenVista Interface Domain (OVID), Medical Domain Web Services (MDWS or “meadows”) and FM Projection, a tool for the MUMPS database that enables structured SQL views of system data for various uses. The open source MIRTH Connect interface engine can work with any of these open platforms to enable easier and more affordable interfacing than proprietary options.
Open platforms in health IT are inevitable. Exactly when OPEN becomes health IT’s de facto reality is impossible to determine. But we can be certain that it will happen because healthcare businesses focused on quality improvement and cost-effective care will demand it.