January 26, 2021
Source: PEW
Photo / Image Source: Unsplash,
Methodology
To understand how hospitals and vendors use APIs, Pew collaborated with RTI to analyze vendor documentation and conduct structured interviews with leadership at health care facilities (such as the chief medical information officer, chief of information services, chief health information officer, and EHR implementation leaders), EHR developer representatives, and other subject matter experts. Interviews were conducted between June and October 2019.
Literature and documentation review
An environmental scan—the process of seeking, gathering, interpreting, and using information from a wide range of sources—compiled peer-reviewed and gray literature (research developed by organizations outside of the traditional academic publishing and distribution channels), federal regulations, and EHR developer documentation. Initial search terms included health care, application programming interfaces, hospital, acute care, inpatient, outpatient, electronic health record, electronic medical record (EMR), electronic health information, exchange of patient data, interoperability, developer, EHR vendor, EMR vendor, and health information technology (health IT). Search criteria were further refined by limiting articles to English with a publication date between 2012 and 2019. Staff used PubMed, Embase, Web of Science, and the Cumulative Index to Nursing and Allied Health Literature to search databases.
Through the initial search parameters, researchers identified 51 articles. A review of the article abstracts refined the search to 21 by eliminating articles that had no relevance to APIs, had an international focus, or were too focused on a specific industry or initiative (such as genetics, blockchain, or IT security). By reviewing key references from the initial set of identified articles on a rolling basis, researchers were able to identify seven additional journal articles; they used the same methodology to review 35 different sources to identify relevant gray literature. Finally, researchers reviewed blogs, technical reports, and key federal rules/regulations pertaining to the use of APIs in health care.
They then reviewed API documentation from EHR developers to also identify costs, applicable terms of service, and the data available by each vendor. To identify the 10 largest vendors for inpatient settings, researchers examined participation in a federal program—often referred to as the EHR Incentive Program and currently called Promoting Interoperability—to require use of EHRs in certain ways. This program covers the vast majority (more than 95%) of the market. Researchers made further revisions based on mergers and acquisitions and involvement in the Argonaut project, which is a private sector-led effort to create guidelines for how organizations can use FHIR to transmit information in a consistent way.2 If required, researchers created developer accounts to access documentation that was not publicly available.
Interviews of key hospital and vendor experts
The findings from the environmental scan informed discussions with EHR developers and health care providers. Researchers developed an interview guide, focused on different API use cases (patient access, CDS, and provider exchange), barriers to their utilization, and future goals. RTI project staff used NVivo software to analyze interview notes. Table 1 depicts the topics covered in interviews.
Table 1
Discussion Topics for API Interviews
Topics | Use | Question categories |
Hospital discussion topics | Current use of APIs | Current use of APIs to extract data from the EHR (read capability) Current use of APIs to enter data into the EHR (write capability) Process for integrating and developing APIs Making apps available to patients and providers |
Future use of APIs | Desirable API capabilities not currently able to use Required API characteristics to support effective use Expanding resources to further use of third-party apps Government role to advance API use Features and use of APIs in other industries | |
Vendor discussion topics | Current use of APIs | APIs offered today Technical requirements to access APIs Terms of service |
Future use of APIs | Future use of APIs Potential for apps and APIs to further health IT objectives Investments in API functionality Hospital requests that are not currently feasible Business model to provide access to and development of APIs Government role to advance API use |
Source: Interviews with RTI International, June 17-Oct. 7 2019
Hospital and developer recruitment for interviews
Researchers identified 60 hospitals for recruitment, equally stratified according to size (small, medium, and large) and setting (urban and rural). Size categories were developed by using the rural/urban bed size categories as defined by the Agency for Healthcare Research and Quality and the U.S. Census Bureau’s urban/ rural designations for counties: fewer than 100 beds for small; 100-300 beds for medium; and more than 300 beds for large.3
Researchers contacted desired hospitals via phone calls and email communication throughout the recruitment period (June 17, 2019 to October 7, 2019) and added further hospitals on a rolling basis via recommendations from professional organizations and through existing professional networks. The final sample consisted of 11 hospitals, some of which represented health care systems with multiple facilities of varying sizes and some of which were standalone facilities. Table 2 displays a de-identified overview of the participating hospitals delineated by size, location, and number of member hospitals.
Table 2
Hospitals Recruited for Interviews
Hospital No. | Location | Rural/Urban | Small | Medium | Large | Type of Organization |
1 | Midwest | Rural | X | System with 10 hospitals | ||
2 | South | Urban | X | System with 1-5 hospitals | ||
3 | South | Urban | X | System with 6-10 hospitals | ||
4 | South | Urban | X | System with 1-5 hospitals | ||
5 | East | Rural | X | X | System with 1-5 hospitals | |
6 | Mid-Atlantic | Rural | X | X | System with 10 hospitals | |
7 | West | Urban/rural | X | X | X | System with 10 hospitals |
8 | East | Urban | X | System with 1-5 hospitals | ||
9 | West | Rural | X | X | System with 1-5 hospitals | |
10 | South | Rural | X | Standalone | ||
11 | Midwest | Urban | X | Standalone |
Source: Interviews with RTI International, June 17-Oct. 7, 2019
To recruit EHR vendors, researchers examined the list of the nine largest vendors in both hospital and ambulatory health care markets, based on participation in CMS’ EHR-related payment policies. Outreach to EHR vendors occurred during the same recruitment period applied to hospitals (June 17, 2019 to Oct. 7, 2019). Researchers obtained vendor contact information from corporate websites, participation in the Argonaut project, professional contacts, and networking at conferences during the recruitment process. The final interview sample size consisted of five of the nine EHR vendors. In addition, interviews included one organization developing health care-focused patient-facing applications for the additional perspective of developing and integrating with EHRs.
There are other issues that cut across care that this research did not delve into, such as patient identity matching, usability of individual apps, or business models to support use of APIs.
As with all qualitative research, the format of this study emphasizes the experiences and knowledge of the participants and should not be generalized to all health care providers and EHR vendors. However, researchers chose interview participants who could provide different perspectives, and their experiences can give insight to observed trends and inform future policymaking.
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