January 26, 2021
Source: PEW
Photo / Image Source: Unsplash,
Building the case for APIs
APIs are the backbone of the modern internet, seamlessly connecting different software programs into a unified view. These tools have made other industries operate more efficiently, yet standard APIs have not been widely implemented for use in hospitals and by health care providers.
The federal government has recognized the utility of APIs within the health care ecosystem and has taken several steps to encourage their use. In 2015, the Office of the National Coordinator for Health Information Technology (ONC) first required the use of APIs in certified EHRs. The Centers for Medicare & Medicaid Services (CMS), in turn, required health care providers to use products certified to those requirements or receive reduced payment from the federal government. To ensure these certified EHRs advance interoperability, in 2016, Congress passed the 21st Century Cures Act (known as Cures), which further required ONC to update its policies to make more information available to exchange via APIs “without special effort.”
In 2015, ONC also required certified EHRs to make a subset of data, called the Common Clinical Data Set (CCDS), available for patient access through an API—albeit not necessarily a standard one—or portal. The CCDS contains critical health information, such as medication lists and vital signs, that the federal government identified as essential.
However, this requirement applied only to patient access, not other use cases such as provider exchange or decision support. The 2015 rules required EHRs to allow patient access to their health information at no cost. The regulations also allowed vendors to use proprietary APIs, rather than ones built on common standards that make it easier for systems to communicate.
A year later, Congress built upon the 2015 requirements by passing the Cures Act, which tasked ONC to ensure that EHRs make “all data elements” in health records available via APIs. That requirement also stated that all EHR vendors must provide documentation for third parties, such as software developers of apps that can be synced into the health record system, to understand how to access information in the record. In May 2020, ONC formally finalized the regulations implementing these provisions, including by defining “without special effort” by indicating that use of proprietary standards or high fees would constitute “special effort”; as a result, the rules mandated use of national, nonproprietary standards and restricted fees. In those rules, ONC expanded the dataset available to patients and renamed it the United States Core Data for Interoperability (USCDI). This set of information contains all data in the CCDS and adds additional important information such as clinical notes and expanded patient demographics.
Contrary to the 2015 provisions, these new regulations do not place any restrictions on the use case, freeing APIs to be leveraged beyond patient access to offer additional benefits such as clinical decision support (CDS) tools and provider exchange. In addition, these regulations require use of the most recent version of FHIR (at date of publication) and the associated implementation guides. These guides, which were developed by Health Level Seven International (HL7), reduce variation in how FHIR can be used to ease integration and data sharing.1 Finally, ONC placed some restrictions on fees and maintained that APIs for patient access to their data must remain free. These final regulations are scheduled to be fully implemented two years after finalization, in late 2022, after a delay due to the COVID-19 pandemic.
In this period of technological advancement in health care, Pew sought to understand what API usage looks like in practice, what progress has been made based on recent policy changes, what gaps exist, what hospitals and vendors envision for the future, and the actions that can advance the use of APIs.
FHIR: A National Standard Critical for Effective APIs
The Fast Healthcare Interoperability Resources (FHIR) standard allows different systems access to modular—or individual—pieces of data and provides more flexibility to obtain only relevant information through an API, such as a medication list or recent diagnosis. For example, apps on patients’ smartphones can use FHIR to request and receive a list of allergies without accessing any other data. Federal regulations have increasingly referenced FHIR as a requirement for data exchange. The nonprofit Health Level Seven International maintains the FHIR standard.
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