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In this episode, we talk to John Orosco, cofounder and CTO for Sansoro Health. John recently attended the ONC Technical Expert Panel in Bethesda, MD along with about a dozen other health IT stakeholders including the major EHRs, digital health application developers, middleware companies and patient advocates. This diverse panel took a deep dive into both the technical and business aspects of using application program interfaces (APIs) in healthcare.
The agenda covered three main areas:
- Challenges and Opportunities to Promote Write APIs
- Challenges and Barriers to Increase the Development of Patient-Facing Apps
- Business/Pricing Models for APIs and App Development
As we hear from John, this set of topics provided important insights to guide future development, collaboration, and policy decisions. It’s not as geeky as it sounds and John, as usual, does a great job of explaining complex technical issues.
About John Orosco
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Dr. Dave Levin: Welcome to 4 x 4 Health, sponsored by Sansoro Health. Sansoro Health, integration at the speed of innovation. Check them out at www.sansorohealth.com. I’m your host Dr. Dave Levin. Today I’m talking with John Orosco, CTO for Sansoro Health. John recently returned from a Technical Expert Panel, sponsored by ONC and this is opting for he and I just quickly deeper if about what went on there, the purpose of the Panel, who attended, what was discussed and what John expects coming out next? So John, thanks for making time for us.
John: Yeah, you bet.
Dave: So, why don’t you start by just tell us a little bit about the group that was there and what they were hoping to accomplish?
John: Yeah, so the group that attended really ran the spectrum from EHR Vendors that were in attendance, Center Epic and All Scripts specifically were there to software providers, middleware vendors like ourselves were there. You had a representative from Microsoft, a representative from Google, you had a patient advocate person, you had other third parties and other Health IT interested parties including a group that did a lot of work with the Argonaut Project in and around Smart on Fire. So, effectively it was 13 individuals all coming together to basically spend time and talking abut APIs and more specifically barriers to API utilization, what it means to do right back API capability. You know, what is it gonna take, what are the complexities in and around being able to do writing up data back into electronic health records. So, that was the premise and then obviously the other topic was business models. What does it mean from a business model perspective for the EHR Vendors that are gonna be making these APIs available, what’s it mean for third parties that want to consume them and what’s it mean for the providers, the health systems that are there and what do they have to do in terms of cost to get these APIs stood up and operational.
Dave: You know, for me, I’m more of a layman when you guys go into these deep technical discussions. I tend to recognize the nouns and the verbs but not necessarily what everything means. What I would observe is this exciting to me to hear that groups like these are assembling and you remember when you and I would first go out and talk to people about APIs for healthcare few years ago, we got a lot of dumb looks and a lot of what are these APIs you speak of and so it’s nice to hear that this is the kind of progress we’re making and that these sort of multi-stakeholder groups are coming together. Let’s talk through each of the three topics that you raised, just you know, sort of briefly. So, the first one you mentioned was looking at writing data back into source, I would presume typically the EHR as the target of that. Of course, this is critically important to closing the loop and making information more actionable and so it’s a critical part of the work that people are doing in interoperability. Tell us a little bit more about, what was discussed particularly around the challenges and opportunities with APIs in this area?
John: Yeah. So, specifically what we talked though was, what does it mean to do writing back into the EHR and why is that so different than reading and it maybe obvious to some but maybe not so obvious to others but what we talked about was, you do read capability inquiries out of the EHR that’s you know, fairly benign from an overall performance standpoint and impact to the database because at the end of the day, the integrity of the data that’s in the database is of the utmost importance. So, when you read stuff out, you really don’t have an opportunity to mess it up or put garbage back in but when you’re doing writing of information back into the EHR, you’ve gotta do it in a way that doesn’t junk up the database and write garbage in and so that’s where the complexity comes in and what we quickly got to was, there are on a spectrum, you know, things that are easy to write and pretty straight forward and still yet powerful things like, being able to post a document summary back in, being able to post a discrete clinical observation or flow sheet back in like a patient score or whatever from clinical decision support. Pretty straightforward but even just those two things which we talked about as a group, those two things alone are pretty powerful because most third parties that want to integrate, yeah, they want to read out some interaction back to the EHR that covers a pretty good, you know, swath of what the third parties would wanna do. Some sort of summary of what happened in their system back to the EHR. So, at least it’s available to folks and then you start getting into other things like, full-blown CPOE around medication, that would be the last thing that people should try to do because of all the complexity in and around it and the one comment that I had made to make sure everybody understood. I said, ‘If you’re gonna do a write API back to the EHR, keep in mind that in order to support that write capability, you’ve got to create a number of different reads that let you read information about what the write expects. So, for example if you’re gonna write a document, you’ve gotta know what document type you’re gonna post it to, you’ve gotta know what document status to put it in and those case can only be known through the actual reference codes that are available in that install and so it’s not just doing the right but you’ve gotta do a bunch of reads and support of that right. That’s what makes it complex.
Dave: What a great summary! I learned something about this topic every time you and I talk. To me this is the holy grail and it’s ultimately how you make things actionable. Maulin Shah and I wrote a white paper on this exact topic where we looked at, you can actually stratify the risk based on the type of API on the activity and it mirrors a lot of what you said. I’m a little bit softer on some of those because you know, my argument is we put wrong data in the EHR all day long. So, that’s a good thing but it shouldn’t be a complete showstopper. I get much more concern when we’re putting things that involve activity, typically orders. I think the risk just goes up and you’ve put it out the additional complexity of well, if you’re doing an order, you got to handle CPOE and even just basic kinds of writes. It’s not as simple as just slamming the document and there’s other things to do. The second thing that, it looks like you guys talked about was a deeper dive looking specifically at patient facing applications. This doesn’t surprise me. We know ONC is making a big deal about APIs to enable patient engagement and patients getting to their own data. So, I suspect that’s partly what was behind this agenda item. What was some of the meat of he discussion there.
John: Yeah, that’s really what we focused on which is this initiative that patients are gonna have access to their data and they are gonna get it now and having these patient facing applications that can be connected and have access to their information is a hot topic and it’s something that CMS, ONC you know, they’ve got a target on to help make that a reality and so what we really talked about was what are some of the things that are going on now related to patient facing apps, you know, obviously everybody saw Apple’s announcement that they’ve got their patient access application that everybody would have access to and the number of health systems that they got connected with across different EHRs. So, we talked a little bit about that, what does that mean and where does that really take us from where we are today. The conversation really was around you know, what does it mean for the providers that wanna offer up this kind of access, not only for reading but the other side of the conversation was what value if any is there in letting patients who have their own data, maybe it’s coming from their Garmin Watch and it’s taking you know, these measurements. What kind of data should be going back into the EHR if any and so that was a pretty interesting discussion because there’s always a debate, right. How much information is useful for a provider, so you don’t wanna just stream and dump a bunch of different clinical data points. First of all nobody is gonna look at it and if they do, it’s almost gonna be too overwhelming for them to discern what that is but there’s probably a middle ground where what if you had a summary of a person’s heart rate, you know, over the last couple of months. That didn’t come from just the provider group and the nurse that was taking it, right but it’s coming from this data that you can at least see. Then the other question is how reliable is that data, right. You don’t know what’s going on with that patient. So, you can’t just rely on that information and so we talked back and forth and then the conversation around how do you validate that data, how do you distinguish data that came from an outside source versus what was entered you know, by trained clinical staff who are putting documentation in an on patient. So, it was a good conversation. I would say you know, at the end of it, it’s not like we walked away with any sort of Epiphany on how this was just gonna change overnight but there certainly is an appetite and a focus on being able to get patients access to their information and I think everybody was in agreement from providers to the EHR vendors to even groups like us who were there in support of that conversation.
Dave: So, to me this part is really straightforward. The information belongs to the patient. In healthcare we’d always act that way but it’s a fact. Patients contributing data to the record either by manual entry or devices that are emerging as part of the internet of health is also intriguing but I think you guys are spot-on and I’ve actually have done some writing about this. If we just fled people with more data, that’s not gonna help. It’s gotta be actionable information and what I foresee is a kind of mash-up that leverages population health and automated monitoring so that the 5,000 patients out there that are reporting their blood sugars are being managed in an automated way and only the ones that really need some attention by a human being are being drawn to our attention and we know that can be done, it’s done in other industries. I predict and watching the Apple Watch for example we’re gonna go through kind of a painful period where we are reminded that just because you can get the data into the system doesn’t mean that makes the world a better place and I’m quite certain you’d agree with that. Let’s pivot to the last topic which is the business model and I’m gonna be really bold here John and I’m gonna make a claim and you can call BS on me which is I’ve watched what can be done from a technical standpoint and I’m increasingly convinced that technology is not the barrier here. I don’t mean to say there aren’t issues to be worked though, there always are. I’ve come to believe frankly, this is largely a geopolitical problem which means it’s largely a business and public perception problem that these are their real barriers to us making advances in this kind of interoperability. Would you agree with that or am I out in left field as I often now?
John: No, that’s spot-on and this was the last topic and quite frankly probably the most intriguing one to listen to and be a part of because you’re right, it’s a less of a technical barrier. In fact, I would probably say, it’s really not a technology barrier. To be honest all of this API capabilities been in existence and we’ve been capable of doing it 15-20 plus years. Every one of the EHRs are set up to do that. It’s a matter of priority and it’s a matter of their own business models and how making an open ecosystem helps either promote that business model concept or quite frankly threatens it. So, the discussion was around, if APIs are available, so to providers and these third parties from vendors that have this data, what is reasonable to expect and one of the folks that was run into a discussion asked, he’s like, how much should APIs cost? You know, sort of fishing for a number but also knowing that he probably wasn’t gonna get an actual number but really to tee up the question. So, it was interesting and so from the EHR Vendors’ perspective the discussion was around well, we wanna make it reasonable, whatever the cost is and the price is we’ve got to over at least our costs to do this development and everybody was nodding up and down, everybody sort of agreed to that premise and furthermore they said, if it’s not a revenue generator or you know, in some ways, it doesn’t make it as a priority for them, right. So, if the EHR Vendors can figure out, not only how to just break even that’s not really gonna help make it a priority but is there’s really a different kind of business model here, it’s gonna make it a much bigger priority and those are the things that the EHR Vendors have to figure out. One of the things that I actually brought up as part of this conversation because the group was asking for what can the Government do or what kind of policies can be put in place to help with this? I think what everybody agreed to and people were talking about was this notion of transparency. So, whatever the business model is, whatever the pricing is you know, there should be some level of transparency so that all of the stakeholders and Health IT sort of have this understanding of what it is and what it’s gonna cost to do this API integration and then one of the comments that I made in addition to that was there should also be consistency and so they asked me to explain that and I said, well, for example, don’t charge ten thousand dollars to one vendor because you think they are okay to integrate with and another vendor comes along that wants to do something very similar and now all of a sudden, it’s a half a million dollars for them to do the same kind of thing.
John: Those are the kinds of activities that you know, you are not saying no but in essence you’re really saying no and you’re making an artificial barrier to being able to do what people want and there’s just no consistency there.
Dave: Yeah, I mean I’ve heard that referred to as passive-aggressive data blocking, these kinds of behaviors. Yeah, I mean, to me this looks like you’ve got some EHR Vendors that have done some terrific work in helping us get to this first generation of clinical technology but you can only go so far on a model of selling and implementing systems and so you know, how do you pivot to a different business model. Personally, I look at the story of Apple Computer and I’m old enough to have been around for the whole story and you know, when they started closed model, they provided everything, hardware, software and I think it was a brilliant way to begin the journey into personal computing but then they pivoted to this open App Store model which is a very different view, that’s the platform view of the world and you know, they must be doing something right, I think they made about six billion in revenue out of the App Store last years and you see companies like Salesforce that are essentially dong the same thing, they started a large application but they’ve now really become a platform and I personally think that’s where most of our industry is headed. My guess is they’ll get their different ways and at different paces.
Dave: Yeah, and I would agree and I think you know, in fairness, let’s just talk about the EHR Vendors, this is where the APIs are most powerful, it’s probably very challenging for them to completely change a business model that they’ve been accustomed to which is you know, controlling the environment, having the applications, not only the core applications for ambulatory and acute setting but all these different departmental applications, all these workflows, they are the only ones that have been able to integrate with themselves because obviously they own that system and can sell those applications. To now flip and become this open ecosystem, you’re a really big ship in a very tight narrow body of water and it’s hard to turn, right and so I think you’re right. I think the Markets gonna push them to do that. They’re all obviously involved, they were at the table and we had really good conversation as part of this meeting. I think there’s a sense that they really wanna get there. It’s just gonna take a little bit of time. You can’t just flip that switch overnight.
Dave: I think that’s a really fair analysis and I’ll add you know, people sometimes bash them and sometimes deserve and sometimes it’s not. I think we have to remember where we started which was doctors were using pencils and pens.
Dave: These large vendors have done a real service by helping us get into this first generation and I think you’re right. They now have to make a big pivot, it’s pretty clear they’re doing it at a different pace in a different way. Let’s wrap this up, what did you leave the meeting thinking is gonna occur next, was there any kind of consensus about what the next steps were gonna be or what’s your own view of that?
John: I think there’ll be ongoing discussions. I think this is one of many technical expert panels that will be done and ONC was there, you know, we had folks listening, talking notes. I think these kinds of conversations will really have influence on just educating everybody, the policymakers, all of that goes into making those policies and I think these kinds of discussions will present itself as you know, having a profound impact on what those policies look like, what laws become you know, written and I think there will be more conversations. I think it was really good to bring a diverse group together like this. I was happy to see that they actually had somebody from the patient advocacy group and somebody that was actually knowledgeable.
John: Not only technically but could really represent what patients want because quite honestly, I’ve been in a lot of meetings and they are not represented and everybody else is just sitting around, talking about what’s best for patients and that sort of thing. You really don’t have anybody there to represent that group. So, I think there’ll be more conversations, I think this is a good way to get connected to other experts and leaders and so for myself personally, I’ll be staying in touch with quite a few of the folks that I met while I was at this meeting.
Dave: Well, that’s terrific and like you, I think if healthcare is about caring for patients and we keep talking about patient centric care probably need them in the room to help us figure that out whether it’s this or a wide variety of topics. So, I couldn’t agree more. Like you, I’m pleased to see a multi-stakeholder groups come together like this because we gotta meet each other on a level playing field and we’re all bringing valuable important perspectives to this. It’s a critical foundation issue. We gotta solve this or we are not gonna fix healthcare in United States. So, I appreciate you and others like you who have both the knowledge and the wisdom and the patience to come together and wok through these things. So, thanks John.
John: Yeah, thank you. I’m happy to participate in these and I actually told the group, you know, I look forward to having future conversations if they would be so kind to have me. So, I appreciate you having me and taking time to talk about it.
Dave: That’s great! Thanks John. You’ve been listening to 4 x 4 Health, sponsored by Sansoro Health. Sansoro Health, integration at the speed of innovation. Check them out at www.sansorohealth.com. I hope you’ll join us next time for another 4 x 4 discussion with healthcare innovators. Until then, I’m your host Dr. Dave Levin, thanks for listening.