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Open and Interoperable Apps

by Dr. Jeffrey Wall
Published on December 10, 2018

There is no denying that electronic health records (EHRs) have revolutionized the health care industry. The ability to access a comprehensive, digitized patient record; use evidence-based tools to make care decisions; and automate and streamline provider workflows and share health information securely between providers and organizations has greatly improved the health care experience for both consumers and clinicians.

With the Substitutable Medical Apps & Reusable Technology (SMART) Health IT platform and Fast Healthcare Interoperability Resources (FHIR), health care organizations can take the benefits of the EHR to the next level.

The open, standards-based SMART Health IT platform allows innovators to create web- and mobile-based apps that run seamlessly and securely across the health care system. This library of apps, available to patients, doctors and health care practitioners, has potential to improve care, consumer engagement, research and public health. FHIR is an open standard for exchanging health care information electronically. It was developed by Health Level Seven International to address the challenges of managing and leveraging EHR information.

In opening our EHR frameworks to third-party companies, I see tremendous opportunity to improve and expand our solutions and provide greater value to consumers.

A national framework for interoperability

The 21st Century Cures Act mandated the Office of the National Coordinator for Health Information Technology to create a Trusted Exchange Framework for interoperability. This framework will build a series of policies and national standards to guarantee the free flow of health care information at the vendor, health system and personal level. Combined with strong disincentives for data blocking, this framework will ensure a national fabric for health data exchange. 

The need for such a network has become clear over the past few years. The members of the CommonWell Alliance, a not-for-profit trade association, are committed to building a nationwide network to facilitate the exchange of health information. Proprietary formats, data standards and business practices should be relics of the past. The promise of better care at lower cost and the potential for true population health management will never be fully realized until a national framework for interoperability exists.

Benefits of SMART on FHIR

The advantages of blending SMART and FHIR in the adoption of health care applications extend to app developers, health care providers and patients, health care institutions and public health. Here’s a sampling of some of the benefits:
  • Simplified app creation and reduced cost and complexity of integrating apps with EHR systems
  • Empowered app users to decide which health IT products are beneficial and valuable
  • Improved return on investment by streamlining internal EHR customization projects
  • Updated decision support rapid response during outbreaks and as guidelines change—without the need to customize for each EHR
  • Transferred ideas, functionality and workflow all in one package that can be distributed widely

Collaboration between app developers and health care

There is often tension between app developers and health care organizations, but this doesn’t have to be the case. While many app developers work for small startups that don’t have much experience in the complex world of health care, partnerships with health care systems can close the knowledge gap and create a productive environment for innovation.

The historical bias within many health care organizations around the perceived difficulties of integrating third-party apps can lead to long sales cycles for app developers and frustrations on both ends of the transaction. While understanding around the newer paradigm of integrating with SMART and FHIR continues to grow, there is still a need for more education on how things are becoming easier.

Developers who position themselves as experts on SMART and FHIR have more success with getting health care systems on board with their standards-based applications. By becoming advocates for open standards, developers can support wholesale change beyond the immediate value of their applications.

Practical steps for EHR app integration

Many organizations are using free-standing web apps to enhance clinical workflow and practice. An ideal starting point for exploring the potential of medical apps on an open platform might be to look at helper apps and inquire about SMART/FHIR versions that can be brought into an integrated workflow in the EHR. 

There are several factors for physicians to consider when looking at medical apps:

  • What value does this app bring to my organization and practice?
  • To what extent does the EHR support the SMART/FHIR specifications?
  • Is the organization ready to integrate apps from both technological and cultural standpoints?
  • How much is the organization willing to spend?
  • Does the organization need a third-party app, or can in-house talent create it?

Security is likely a top priority for any health care organization as it considers the viability of using apps. Credible vendors will take their apps through a rigorous validation process to assess security, functionality and design before publishing to an app store. Apps must protect not only the privacy and data of patients and providers but also the quality of the user experience. It is not a one-size-fits-all situation, so health care institutions will need to evaluate the clinical appropriateness, accuracy and usefulness of each app based on their organization’s needs.

Health care applications now and next

SMART and FHIR are still in their infancy, as are most EHR implementations. We have not hit a critical mass of apps that are available, but many EHRs are beginning to feature apps on their website. With more than 2,600 developers in the sandbox, we are just getting started.

Moving forward, addressing how to connect the rich data that patients amass in their mobile medical apps with their clinicians in the EHR will continue to be an important conversation. Provider-facing SMART and FHIR apps that run in the EHR and connect to consumer-facing apps, such as Rimidi, can provide that connection. Funders and developers of mobile health apps should focus on not just the member app but also on facilitating the connection to the medical provider’s EHR.

Data availability, redundant practices and non-integrated workflows are some of the hurdles we need to overcome before the full potential of medical apps is realized. We must accept SMART and FHIR as the de facto standards for app development. EHR vendors must be willing to build and extend APIs to fully support the specifications. Other specifications, such as CDS Hooks, will also need to develop and be fully supported if we expect to see meaningful integration into clinical workflows. We are still very early in this process, but as the standards mature, I predict an explosion of innovation that will take health care to places unknown.

Although there is some apprehension among health care providers about the value of introducing apps into the EHR, there is even more excitement about the possibilities. If health care organizations are thoughtful in their selection of apps, the likelihood of improving workflows, increasing efficiency and gaining more clinical guidance and relevancy is great.

Cerner’s ambulatory EHR and practice management software supports physician practices of all sizes and more than 40 specialties. Learn more here.