Liberate Applications with API-based EMR Integration

By Dr. Dave Levin

My journey into the world of API-based EMR integration began while serving as the CMIO for the Cleveland Clinic. One of our crazy-smart clinicians had developed a terrific little application to help doctors manage the dosing of heparin, a widely-used, powerful and dangerous blood thinner. Managing heparin can be a real challenge since each patient responds in different and changing ways over time. Give too much and you can seriously injure or kill a patient. Give too little and the drug won’t work – which can also lead to injury or death. This heparin dosing calculator was just what the doctor ordered.

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If you build it, will they come?

But, there was a problem. One that virtually all clinical applications face. The calculator, built as a web-based application, did not integrate with Epic, the electronic medical record (EMR) used at Cleveland Clinic. The vision of providing clinicians with a useful and important tool was stymied by the difficulty of accessing and using the calculator. Here’s what the workflow required:

  1. Leave EMR application.
  2. Open a web-browser.
  3. Find and navigate to the calculator web-page.
  4. Enter the patient data needed to make the calculation.
  5. Take note of the recommended dosing.
  6. Return to the EMR to enter new orders.

Sure, clinicians could do all this, but not many did. It just isn’t practical or reasonable to ask busy clinicians to adopt this kind of workflow. It requires too many steps, takes too much time and introduces safety concerns which are inevitable when clinical data has to be transcribed from one application (the EMR) to another (the calculator). As you might imagine, this kind of double-entry is also annoying to the user. After all, they know that the data the calculator needs like the current dose, lab tests, and patient weight, is already in the EMR and rightly question why it’s not being leveraged properly!

You can look across a wide variety of applications and use cases – from clinical decision support to population health to unified communications to patient engagement and find exact parallels to this awkward, wasteful and unsafe approach. It’s also expensive. As noted by Cleveland Clinic CEO, Toby Cosgrove, in a recent interview, lack of interoperability is a major cost driver.

It’s all about the workflow.

All of this changed when we leveraged the power of APIs to integrate that calculator into the EMR and the clinical workflow. Now, the clinician could easily access the calculator from within the patient record with one click. The calculator was automatically populated with the data available. A workflow of six painful steps was transformed into a safer, saner and nearly-seamless experience:

  1. Launch the calculator from inside the EMR.
  2. Take note of the recommended dosing.
  3. Enter new orders in the EMR*.

*It is technically feasible to automate this even further by using an API to enter the new order into the EMR, but this raises some interesting “geo-political” issues, which we elected to side-step at the time.

The results were inspiring and heartwarming. Use of the calculator began to rise and complications from heparin therapy began to decline. End-users told me, “This calculator is much better than the old one.” Of course, the calculator was exactly the same – the added value to the end-user came from effective, robust integration with the EMR. Given this kind of response, when you look at studies like the recent systematic review of Clinical Decision Support in JAMIA that that showed highly variable results, you have to wonder how much weak EMR integration limits their impact.

I see this all the time:

  • Great applications that end-users don’t think are great because they don’t integrate
  • Developers who are frustrated because the reputation (and adoption) of their application is suffering, not because of anything inherent in the application, but simply because EMR integration is weak or non-existent, and
  • Health IT leaders who yearn to say “yes” more often and provide solutions that transform workflows and produce better outcomes.

But wait, there’s more!

When properly designed, the benefits of API-based EMR integration go far beyond enhancing workflow and adoption:

  1.  An EMR Agnostic Approach. APIs can be plug-and-play across different EMRs so developers no longer need to worry about those differences. This is a huge advantage over traditional integration methods, EMR vendor-specific APIs and FHIR**.
  2.  Robust integration and agile development. APIs are perfect for agile development and can develop and deploy enhancements in days or weeks. The impact on product management and evolution is profound.
  3. Real-time, bi-directional data exchange. Applications can get the data in real-time and both read & write EMR data. Posting information from an application back into the EMR injects it into the clinical workflow making it truly useful and actionable.

**FHIR is not standardized across different EMRs. Unfortunately, this means application developers will have to contend with different FHIR implementations as adopted by different EMR vendors.

Forget HL7 and skip the queue.

Visit any U.S. health system and you will almost certainly find a substantial backlog of integration projects and lots of frustration at the slow pace of moving through the “integration project queue.” If you are in application sales or part of a health system’s integration team, you probably dread it when the topic of integration comes up. Those are the meetings where everyone kind of stares at their shoes because they know integration is essential, costly, time consuming and unlikely to happen quickly. The integration team is always caught in a bind since demand consistently exceeds supply and there is little flexibility in prioritizing new work because so much of what is already in the queue are “must do” tasks related to compliance, regulatory or key strategic health system needs.

APIs can eliminate the dreaded integration project queue since they don’t have to rely on traditional EMR integration approaches like HL7 and flat-file extracts. It is possible to deploy and maintain them in a few hours using a highly scripted and industrialized approach that has minimal impact on busy integration teams.

The implications for both health systems and application developers are enormous. Each step – from sales to implementation to maintenance – are radically shortened and simplified. Health systems get the benefits faster and with much less labor and expense. Application developers close sales, deploy and get to revenue quickly. Integration teams are empowered with a whole new way of working and balancing priorities. It’s a win for everyone.

It’s time to liberate applications and unleash the value of EMRs.

As the heparin calculator story shows, API-based EMR integration can be a game changer. Application developers benefit from robust, bi-directional, EMR-agnostic integration that rapidly deploys and can quickly evolve. Health systems benefit by getting from vision to execution much faster and at substantially lower cost. Everyone benefits from applications that work better because of seamless data exchange and integration into clinical workflows.

APIs truly liberate applications and their developers while helping health systems unleash greater value from their EMR. Viva la revolución!

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Dave Levin, MD is the Chief Medical Officer for Sansoro Health where he focuses on bringing true interoperability to healthcare. Dave is a nationally recognized speaker, author and the former CMIO for the Cleveland Clinic. He has served in a variety of leadership and advisory roles for healthcare IT companies, health systems and investors. You can follow him @DaveLevinMD or email Dave.Levin@SansoroHealth.com