January 26, 2021
Source: PEW
Photo / Image Source: Unsplash,
Overview
Technology has revolutionized the way people live their lives. Individuals can use smartphones to access their bank account, shop from almost any store, and connect with friends and family around the globe. In fact, these personal devices have tethered communities together during the coronavirus pandemic, allowing many people to maintain much of their lives remotely.
Yet when it comes to accessing and sharing their health information, hospitals and physician’s offices can frequently ask patients to go through arduous, arcane steps, such as submitting forms using a fax machine or paying fees to obtain their records, or they simply deny patients access to their own records. And health care organizations often don’t seamlessly exchange data—a process known as interoperability—and instead require patients to serve as the intermediary, manually transferring their data from one place to another.
To address these challenges, health care can adapt the same technological approaches that have revolutionized other industries by incorporating digital tools called application programming interfaces (APIs). These tools allow personal finance websites to aggregate information from banks and credit card companies to provide consumers a complete picture of their spending habits, for example, or let travel services compare flights from multiple airlines without the user having to visit each airline’s site individually. If standard APIs were broadly adopted in health care, patients could access and compile their data from multiple providers while clinicians could process complicated information and make care recommendations. APIs would also offer other benefits, such as facilitating the exchange of clinical data among health care providers.
This report will focus on three health care benefits of APIs:
Patient access to data.
The incorporation of clinical decision support (CDS) tools, such as risk calculators or apps that provide recommendations for prescribing antibiotics.
Provider-to-provider exchange of information.
When patients have access to their records on a personal device via APIs, they can track and manage their health outside of the doctor’s office or hospital. They can integrate their information in health apps on their smartphone to promote disease management, allowing them to digest information outside of a short clinical visit and track their health over time.
APIs can also help clinicians more effectively use patient data from electronic health records (EHRs) to make decisions. Health care providers can integrate some applications into the EHR to offer a broad range of these CDS tools, giving clinicians the opportunity to pick the functions that work best for them. However, these tools may introduce bias into care, such as if an application analyzing potential pictures of skin cancer is tested primarily on light-skinned patients.
And when two providers, such as a primary care physician and a specialist, need to exchange information about a shared patient, they must frequently do so using full clinical documents, which can be hundreds of pages long and cause providers to struggle to find and extract relevant information. This situation contributes to clinician burden and often results in patients having multiple, incomplete records across different sites of care. APIs can allow providers to exchange only the information needed to inform care decisions and in a digital format, thereby mitigating the need to exchange full clinical documents.
Improving the way providers communicate through standard APIs could advance care coordination, reduce unnecessary testing and procedures, and save money. Despite the potential for improving provider exchange, APIs have not been broadly implemented in health care.
However, APIs can’t be broadly adopted if technology developers implement them in proprietary ways so that they work with only one EHR and apps have to be coded differently for each system with which APIs interact. But standards—such as the industry-developed Fast Healthcare Interoperability Resources (FHIR), which is a standard for exchanging health care information electronically—ensure easier use of APIs. FHIR can offer access to individual pieces of information—such as a list of medications—instead of a broader document containing more data, some of which might be unnecessary or patients may not wish to share.
Another issue is that although most APIs can only read information from EHRs, several opportunities exist to promote the ability to input information back into electronic records, known as write access functions. This action would allow CDS tools to offer additional capabilities and benefits to clinicians and enable patients to contribute to their own records, by changing an address, updating symptoms, or correcting errors.
Federal regulations finalized in 2020 require the use of FHIR and expand the dataset that must be available for exchange via APIs, but the rules did not address write access. Those regulations are scheduled to take effect in 2022. Although these regulations are critical, they do not mitigate the need for significant additional policy and technology developments in order to successfully integrate and prioritize APIs within health care. Policymakers can take additional measures to promote the use of APIs and incentivize new capabilities through both legislation and additional regulation.
Despite these policy advances, outstanding questions remain on the current capabilities of APIs, the gap that the new regulations will fill, and additional barriers to more widespread use of these tools to improve data exchange. Obtaining a snapshot of the current state of the industry can both provide a benchmark to measure whether policies successfully improve use of APIs and to identify opportunities where additional policies are needed.
To evaluate the current and near-future uses of APIs, The Pew Charitable Trusts collaborated with RTI International, an independent, nonprofit research institute, to analyze publicly available EHR vendor documentation to understand their terms of service and the data made available via their FHIR APIs by each product developer. Additionally, the research included structured interviews conducted between June and October 2019 with high-level staff from EHR vendors, hospitals around the country, and other experts.
The research revealed:
Use cases. Of the three use cases examined (patient access, clinical decision support, and provider-to-provider exchange), hospitals most frequently implemented APIs for patient access and clinical decision support. APIs have not yet appeared significantly for other uses, such as data exchange among health care providers treating the same patient.
Data exchange capabilities. Vendors vary significantly on the data elements they permit for exchange via APIs built on the FHIR standard. This disparity significantly affects the amount of information that can be exchanged via APIs, as does lack of write access.
Terms of use. The agreements that govern the relationships between care providers, EHR vendors, and third-party application developers in the use of APIs can dictate costs, who retains the intellectual property of the application and API, and how apps are developed and deployed. In the EHR documentation reviewed, many of the terms and conditions lacked critical details, including on costs.
Future promise. Interviewees identified three areas as critical future opportunities to improve the use of APIs in health care settings: enabling their use to enter data into EHRs and not just extract information, incorporating applications more seamlessly into clinicians' workflow, and adding more standard data elements, such as images or cost information.
These findings provide insights that can inform policymakers as they consider accelerating both patient access to their medical information and more effective use and sharing of data by health care providers. As APIs become more integrated into EHRs, policymakers should focus on policies that:
Improve privacy and security.
Build out the ability to enter data into records.
Increase API use for data exchange among providers.
Include more data elements for exchange.
Monitor costs.
Guard against health inequities with CDS tools.
How can such practice impact your health? how? Why?
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