Federal Policy Drives Healthcare API Adoption, But EHR Data Barriers Persist

Application programming interface (API) adoption is common in many business sectors like travel and finance, but adoption across healthcare and integration with EHR systems has lagged.

However, there is an evolving landscape with steady progress toward greater adoption and use of APIs, partially driven by federal policy, according to preliminary findings from a national survey of digital health companies.

Put simply, an API sends information back and forth between a user and a website or app. For example, APIs allow travel services to cost-compare flights from separate airlines without the user visiting each website.

In healthcare, patients now use apps to monitor their health-related goals and participate in informed discussions with providers through patient portals.

About six in 10 individuals nationwide were offered access to their patient portal, and nearly 40 percent of patient portal users accessed their health data through a smartphone health app in 2020, according to ONC.

On the provider side, clinicians use apps to expand their EHR capabilities to provide clinical decision support (CDS) tools for better patient care. Greater access to health data is also being used to inform clinical and biomedical research.

However, challenges to API integration with commercial EHRs among digital health companies persist.

Barriers include high fees, a lack of realistic clinical testing data, difficulty accessing API endpoints, and a lack of standardized data elements, according to the national survey of 104 digital health companies conducted by the Center for Clinical Informatics and Improvement Research (CLIIR) at the University of California San Francisco (UCSF).

"Right now, if I wanted to build a product off airline data, I can go to one place, and it's all there, but we don't have one place to go to get EHR data," Julia Adler-Milstein, PhD, director of the CLIIR and professor of medicine at UCSF, told EHRIntelligence in an interview. "You have to work through each of the different hospitals or health systems, and they each have their own EHR. It's not easy from the start."

She also noted that even when the data is available, app developers must have a robust understanding of healthcare to integrate commercial EHRs using APIs. For instance, understanding a patient's medication list requires knowledge of the health conditions and medications.

"In travel or transportation, you don't need quite that same level of expertise and knowledge to come up with a product or service that might be useful," Adler-Milstein suggested. "Not to say it's easy, but I just think healthcare is particularly complex."

"There's not just one big barrier," she added. "If we want to move this field forward, we'll have to take action on multiple levels."

Many API EHR integration challenges are about the data itself.

"If you look at the set of top barriers, like lack of realistic clinical testing data and standardized data elements, a lot of it seems like it's not about the API," Adler-Milstein said. "You can get the API to work, but the challenges come in once you're trying to or working with the data itself. Those are harder to solve."

"Fixing data integrity issues, that's a harder thing for policymakers to work on, but it is critically important because if the data themselves aren't high-quality and easy to work with, then there isn't that much value accessing them," she emphasized.

However, findings from the survey revealed that recent policy changes are helping vendors adopt FHIR-based APIs more easily. 

The 2015 Edition Cures Update made several changes to the ONC Health IT Certification Program, including requirements for FHIR-based standardized API for patient and population services. Most certified health IT developers must update their certified Health IT Modules by December 31, 2022.

Almost three-quarters (74 percent) of digital health companies surveyed reported using standardized APIs directly required by the regulations. Half of the respondents (49 percent) said that the Cures Act regulations are making it easier to provide customers with APIs.  

"These results suggest that these ongoing deadlines and set of regulations are really helping the industry, and people are paying attention to them," said Adler-Milstein. "Seeing that these regulations have had this impact is a powerful story of policy gone right. We should celebrate because it's not always easy to see that policy has intervened in a productive way."

On the other hand, the preliminary survey findings also show that 32 percent of digital health companies don't know whether the 21st Century Cures Act API regulations have impacted their ability to develop standardized APIs.

Adler-Milstein noted that this is not necessarily a bad thing.  

"These are companies that can't make the direct connection between what they're able to do today and the policy foundation that has been put in place to get us there," Adler-Milstein said.

"There is certainly a subset of digital health companies that are really engaged in the policy efforts and follow what ONC and CMS are doing, but there are a lot of other digital health companies that are not," she added. "I think those companies don't really need to know all the specifics of the policy."

"The whole point is we want to create an ecosystem in which digital health companies can come up with solutions and take them to market and create value, and that, in some ways, seems like what's happening here," she added.

While adopting standardized APIs in healthcare has become more widespread, many survey respondents still reported relying on proprietary APIs. More than 60 percent of companies reported reliance on non-standardized APIs and non-API-based integration approaches (69 percent and 65 percent, respectively).  

"We're in this very dynamic time, where we're still seeing a lot of use of old-style integration approaches, but also a lot of use of the most current FHIR-based APIs," Adler-Milstein said. "I would expect that over time, we will see some of the older methods of integration fall away, but we're not there yet."

Digital health companies can complete the ONC and California Healthcare Foundation-funded survey here.

"We have results from 100 companies, and our goal is to get to 300," Adler-Milstein said. "I would be surprised if the findings change a lot, but we're still hoping to hear from more companies."