2016: Year of the Healthcare IT Mashup?

Electronic health record software manufacturers have taken early steps into application programming interface publishing, and savvy health informaticians have already created some clever mashups with them.

In late 2013, a study group of scientists released "A Robust Data Infrastructure," more commonly known as the JASON report, commissioned by ONC and AHRQ, which subsequently published the report in 2014.

(JASON is an initiative within the MITRE Corporation, a nonprofit that operates research and development centers sponsored by the federal government. JASON is spelled in all caps, but it is unclear what, if anything, it stands for.)

At any rate, the final rule for meaningful use stage 3, published in October 2015, can be found here (Google searches surprisingly don't rate this link highly, but ONC has yet to format the rules on its own website). That final rule contained language that didn't capture the headlines at the time, but was very much in the spirit of that 2013 JASON report: Electronic health record software should adopt application programming interfaces (APIs). 

The use of APIs in stage 3 certified software is somewhat narrowly prescribed to potentially replace an EHR vendor's requirement to provide a patient portal, with APIs that any number of patient engagement technologies could plug into. This would bring a word to healthcare that hasn't really been heard before: mashups.

Mashups have been on the scene for a decade or more in the rest of technology. An early example combined the Chicago crime database with Google Maps. The crime database didn't have to add map functionality, and Google Maps didn't have to learn how to interpret crime data. The mashup just gave users a simple-to-understand combination of the two.

After that proof of concept, mashups took off for several years. Popular Web destinations such as Twitter and Facebook published APIs in sufficient quantity that we saw a flowering of mashups of all imaginable shapes and sizes.

Electronic health record software manufacturers have taken early steps into API publishing, and savvy health informaticians have already created some clever mashups with them. One such expert is Kristen Wilson-Jones of Sutter Health, whose efforts I profiled in May of 2015.

I spoke with Wilson-Jones again in November, and was fascinated to learn of the many tools Sutter is using to extend its IT capabilities. In addition to the hotspotting initiatives I mentioned in the earlier column, to identify frequent emergency department utilizers in a Camden Coalition-style initiative, Wilson-Jones is using tools such as MuleSoft to optimize workflows between Epic and Sutter's call center, which runs Salesforce.com, to track conditions such as COPD.

"Right now they're doing a lot of paper-pushing between the labs and the pulmonologist groups. So we're helping out with streamlining that for them, and gaining insights into what's inside these PFT reports," says Wilson-Jones, chief technical officer of research, development, and dissemination (RD&D) operations at Sutter.

Wilson-Jones finds inspiration all over tech, including a project I had not previously heard of, called IFTTT. "It's consumer-based social media stuff," she says. "I think there's over 360 participants now, where you can actually do these kind of workflow rules engine [integration] between consumer apps. We're doing this kind of stuff, but in healthcare land."

The Camden-like hotspotting project, which leverages Boston University's Project RED and Alfresco's Activiti open source business process management technology, involves non-Sutter providers in the area, and even one public health provider who doesn't run Epic, so much of the work is about the legal agreements that allow data to be shared between the project participants, Wilson-Jones says. Once the hotspotting project goes live—Sutter is targeting February as a go-live date—participants will be able to spot trends including patients who might have narcotics issues, or even those who have a history of posing a security threat to hospital personnel, she says.

Part of what is allowing mashups such as Sutter's to flourish is a temporary moratorium announced by Epic last year on levying fees for API usage. In Epic's case, it's a five-year moratorium. Let's hope the benefits of mashups are so great that when the end of the fifth year rolls around, Epic finds a way to make the moratorium permanent, and to continue to fund its business by other means—or else to make sure that the cost of mashups, on top of the staggering cost of health IT already, doesn't inhibit innovation.

ONC will be watching EHR vendor behavior as these mashups flourish. As Wilson-Jones puts it, "no one thing will ever be all things. There will always be data about a patient somewhere else." Providers "are going to need the kind of integration interoperability that we're putting together. Data about a patient will always be in more than one place, and you will have more than one organization working on it. That's what our stuff addresses. We glue all that together."

Of course, tension between the mashups and the "we do it all" software initiatives isn't going away. After the initial flourishing of mashups on the Web, some of the larger API publishers, such as Twitter and Facebook, cracked down on API usage that the publishers deemed not to be in the business interest of the publisher. So it's not just an issue of the cost of API usage. In certain cases, certain APIs themselves may not be offered forever by a large organization.

As healthcare becomes more dependent on APIs and the mashups they permit, the ongoing healthcare interoperability debate—which until now has been dominated by mere data format issues—will pivot to the more subtle issues that an API-driven healthcare IT world introduce.

The HL7 Argonaut Project, which I wrote about more than a year ago, is one multi-vendor effort to make this pivot. It is my hope for 2016 that many more mashup champions, such as Wilson-Jones, show policy makers just how important it is that the innovation continue in as unfettered a manner as possible. The JASON report laid it all out in 2013. Now it is time for the healthcare industry to build it.