Published in Healthcare Informatics.
I was talking with a colleague recently about interoperability when he casually remarked that healthcare IT (HIT) is emerging from the preindustrial age and that Application Program Interfaces (APIs) and web services will industrialize data exchange. He made the case that APIs are revolutionizing healthcare in the same way that the adoption of interchangeable parts transformed manufacturing, economies and the world. It’s a brilliant analogy.
In the mid-18th century, Frenchman Honoré LeBlanc suggested that manufacturing firearms could be greatly improved by adopting interchangeable parts. The idea was picked up by Thomas Jefferson while in France and carried back to the US. In 1798 Eli Whitney convinced the US Congress he could use this approach to manufacture firearms for the US military. He eventually produced over 25,000 firearms in a relatively short time.
Previously, making and repairing firearms was labor intensive, time consuming and required highly skilled craftsmen. That sounds exactly like building and maintaining HL7 and other traditional interfaces. Visit a large health system or digital vendor and you will find highly skilled experts engaged in complex, lengthy and expensive efforts to produce what are often one-of-kind solutions. They are modern day artisans. The resulting product, which is often built to satisfy a specific need, is not reproducible or scalable. To be clear, I am not blaming the artisan. The fault lies, not with them but with the underlying technology.
Fortunately, APIs are a well proven, secure alternative that are widely used throughout the digital economy. APIs are how Amazon and UPS collaborate to let you know your package has just been delivered. They were essential to Google’s rapid growth and ability to extend the power of its inherit capabilities. They allow financial institutions to securely exchange important data. When companies expose their API’s to their partners and customers, magic happens. Properly designed APIs are like interchangeable parts in their impact on IT, businesses and the overall economy. They industrialize data exchange and boost collaboration. The good news is that powerful APIs are available in healthcare now. They are driving the shift away from the pre-industrial blacksmith model to the industrial approach.
Some believe that FHIR will work this way too. They may be right, but from what I read, FHIR appears to be following the same course as previous consensus “standards” in healthcare. There is a spec, but vendors are free to customize. It’s like two chefs with a recipe. They may start with the same list of ingredients but one adds a dash of tabasco and the other leaves out the garlic. The results are similar but not identical nor interchangeable. FHIR certainly has benefits, but FHIR alone may not industrialize healthcare data exchange.
To deliver on the promise of industrialization, APIs should be standardized across platforms and delivered via end-to-end web services. This creates a plug-and-play environment for seamless data exchange and truly interchangeable applications. The cost of interoperability falls dramatically. Innovation, driven by market forces and freed from depending solely on artisanal craftsmen, takes off.
There are other fascinating parallels between the industrialization of firearms and healthcare data exchange. For example, LeBlanc struggled to get traction in the French gun market due to resistance from competing gunsmiths. They could see the threat to their craft-based approach. I’ve observed the same attitude in some vendors and a few IT professionals. Innovation like APIs can dislodge incumbents and empower new players. Some feel threatened. They adopt defensive postures and erect administrative barriers. Does your vendor make it hard or fail to even mention that you can use APIs? If so, they may be behaving just like those French gunsmiths.
In my view that’s a losing strategy. A better approach will usually win out. Economic pressures force a change. Resistors get left behind defending a shrinking market share. Adopters sprint ahead capturing and expanding the market as they add ever greater value based on scalable, reliable and re-usable approaches that work for them and their strategic partners and customers. The Apple App Store generated $28B in revenue in 2016. APIs were an essential enabling technology for that success – a success shared in by customers, Apple and App Developers.
It seems resistance isn’t just futile, it’s bad business strategy. And it’s bad for a healthcare system that desperately needs innovation.
Dr. Dave Levin has been a physician executive and entrepreneur for more than 30 years. He is a former Chief Medical Information Officer for the Cleveland Clinic and serves in a variety of leadership and advisory roles for healthcare IT companies, health systems and investors. You can follow him @DaveLevinMD or email DaveLevinMD@gmail.com.