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A new breed of interoperable EHR apps is coming, but slowly

Pioneering work with the FHIR API is beginning to pay off in interoperable applications for EHRs. And that could mean sweeping changes in healthcare.

SAN FRANCISCO -- It's an app-fueled world, and healthcare is starting to catch on. That was the message during the 2018 American Medical Informatics Association conference here from electronic medical record vendors, developers and provider organizations, many of which have been quietly working on EHR apps that can be used across different EHR systems and eventually shared or even sold commercially.

These efforts come at a time when the demand for truly interoperable healthcare data has never been stronger, particularly from patients looking for more access to their medical records. This new breed of interoperable EHR apps was hailed by attendees as a critical step forward for the traditionally slow-moving and siloed healthcare system.

"We finally have the plumbing in place to use, distribute and deploy apps for health IT," said Isaac Vetter, senior software developer at Epic, based in Verona, Wis., who has been involved in creating standards to make EHR apps work on any system, including rival Cerner's. 

The new EHR apps have been created using versions of the SMART on FHIR API, which is a widely accepted standard that operates as a building block for both software development and the exchange of information. Although it is still very early in the process, David McCallie, M.D., and senior vice president of medical informatics at Cerner, based in Kansas City, Mo., said EHRs are beginning to operate like smartphones -- as platforms for which developers will write applications.

"What would it look like if an EHR was like a platform?" he asked. "There is no reason not to see plugin services and innovative ideas that will fill the gaps not covered well by the vendor."

And that is exactly what the University of Utah Hospital system has done. The medium-sized healthcare organization, with five hospitals and 12 community clinics, uses Epic, but the hospital decided to take matters into its own hands and to create EHR apps to improve the provider's experience.

"Our vision was to imagine that, as a clinician, it is a joy to use the EHR," said Kensaku Kawamoto, M.D., and associate chief medical information officer at the University of Utah Hospital.

Against a backdrop of some hearty laughter for that comment, Kawamoto described a number of custom and interoperable applications his team has developed since 2016, including those for capacity management, neonatal bilirubin measurement, diabetes prediction and surgical referral.

"This is feasible to accomplish, and it is doable now," Kawamoto stressed.

That's certainly true at Intermountain Healthcare, which began its move into interoperable EHR apps with a choice very common in other industries: The hospital took an open source application and customized it, said Scott Narus, medical informatics director at Intermountain, based in Murray, Utah.

The pediatric growth EHR app is in widespread use today, Narus said, and it's very popular with both providers and patients. And not only does the app work on Intermountain's Cerner installation, it also works at the Utah hospital system. The two groups regularly work together and swap apps, as needed.

"We've demonstrated that sharing application enhancements work across organizations," Narus said. "This is real. This really does work."

In fact, there is enough momentum around the creation of EHR apps that Cerner, Epic and large providers like Intermountain have started small-scale, online "app marketplaces," where provider systems can shop and software developers can eventually create and market their own applications -- a process that's widely in use in other industries.

But unlike other industries where standards are largely set in stone, healthcare still has a lot of work ahead of it, Narus warned.

"FHIR has been standardized a little bit, but not enough," he said.

The API needs to support additional use cases and the ability to write and not just read. Plus, semantic interoperability -- where every product and organization refers to the same thing the same way -- continues to be elusive.

"You're never going to become truly plug-and-play unless you have something like that," he said.

Narus also said he hopes electronic medical record vendors will open up their systems further so providers don't have to go hunting for data.

"Data is not always where we think it is, and [queries] don't always come back as expected. We just have to work through these things."

Cerner's McCallie summed it up neatly. "Who knew healthcare was so hard?"

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